Every finding on record at North Dade Nursing and Rehabilitation Center

Based on observation, record review, and interviews, the facility failed to maintain a safe, clean, sanitary, homelike environment in one (J hallway) out of three nursing stations with trash bins left open and unattended, residents' rooms and floor surfaces were soiled and had foul odors, overflowing trash, visible debris, unflushed toilets, dirty furnishings, soiled torn linen and unrepaired structural damage in multiple resident rooms. There were 210 residents in the facility at the time of the survey The findings included: Observation on 01/25/26 at 6:18 AM, revealed three uncovered trash bins with trash left unattended in the J hallway. (photo evidence) On 01/25/26 at 6:28 AM Staff M, Floor Tech stated, I left the carts in the hallway. The protocol is to take the carts outside to the dumpster one by one to avoid leaving trash in hallway and keep the bins covered for infection control. On 01/25/2026 at 07:58 AM, room [ROOM NUMBER]C was observed to have a brown-colored substance splashed on the wall. The floor surface was sticky. The trash bin was overflowing with trash. On 01/25/2026 at 08:11 AM, room [ROOM NUMBER]C was observed to have a sticky floor surface with black dust-like debris present. A foul odor was noted in the room. On 01/25/2026 at 08:39 AM, room [ROOM NUMBER]B was observed to have trash overflowing from the bins. A foul odor was present inside the room. On 01/25/2026 at 08:51 AM, room [ROOM NUMBER]B was observed to have black dust-like debris on the floor. The toilet seat had a yellow stain. The bathroom floor surface was sticky, and pieces of paper were present on the floor. On 01/25/2026 at 10:13 AM, room [ROOM NUMBER]B was observed to have a liquid resembling urine on the floor. A foul odor was present. On 01/25/2026 at 10:15 AM, room [ROOM NUMBER]B was observed to have feces-like material inside the toilet that had not been flushed. On 01/26/2025 at 10:41 AM room [ROOM NUMBER]B had feces-like material dripping from the toilet seat to the inside of the toilet. Observation on 01/25/2026 09:22 AM, room [ROOM NUMBER]B noted the floor surface was sticky with black dust/dirt-like debris and scattered paper on it and cups under one of the beds. The side tables were visibly dirty and sticky to touch. The toilet contained feces-like material and had not been flushed. There wall behind the toilet had a broken tile and a hole. Observation 01/25/2026 at 09:24 AM, revealed Resident #113's linens had a hole, visible stains and had a foul odor. On 01/26/2026 at 10:36 AM, Resident #113 was observed to have visible stains and a hole on his linens. The linens had a foul odor. Review of Resident #113's clinical records revealed the resident was readmitted on [DATE], with an initial admission date of 06/22/2022. Clinical diagnoses included schizophrenia and major depressive disorder. The Quarterly Minimum Data Set (MDS) dated [DATE] cognitive section documented intact cognition. The MDS further indicated that the resident requires setup and cleanup assistance with eating, oral hygiene, and toileting hygiene, and requires supervision or touching assistance with bathing, dressing, footwear, and personal hygiene. The resident's care plan identifies a self-care deficit requiring staff assistance with activities of daily living and includes interventions to provide setup of basic hygiene items, ensure items are kept within easy reach, and provide assistance as needed. During an interview on 01/27/2026 at 11:44 AM with Staff U, Housekeeping Aide was asked how often garbage in the bathroom is changed and rooms cleaned; translation assistance had to be provided by the surveyor because Staff U, Housekeeping Aide noted she does not speak English revealed she works the 7:00 AM to 3:00 PM shift, checks rooms three times daily and cleans the rooms once per day with water and the facility-approved detergent for cleaning and indicated that when floors are sticky, the rooms are waxed. Interview on 01/27/2026 at 12:12:01 PM, the Housekeeping Director revealed housekeeping prioritizes rooms identified as requiring more attention, including rooms with odors, food, or garbage accumulation. November 15, 2025, was the last time floors were waxed and that housekeeping planned to wax the rooms again on the following Monday. Floors are buffed daily after breakfast. When asked specifically about the stickiness reported in room [ROOM NUMBER]B, he stated that the room requires frequent attention, and no one had reported stickiness and the wax used is not sticky. Interview on 01/27/2026 at 12:35 PM, the Director of Maintenance was asked about the identified concerns, he revealed rooms requiring repair are tracked daily, maintenance staff work Monday through Thursday, with three staff members assigned from 7:00 AM to 3:00 PM and tiles are checked weekly. On 01/28/2026 at 3:35 PM the Infection Preventionist revealed that Resident #113 does not want anyone entering the room for cleaning. The Infection Preventionist revealed that while the room is considered the resident's home, leaving the room uncleaned may present safety concerns, and that changes in hygiene or refusal of cleaning may indicate potential underlying medical conditions. On 01/28/2026 at 3:47 PM an interview with the Director of Nursing (DON) revealed that soiled or damaged linen are required to be removed and sent to the laundry and are evaluated by housekeeping for disposal if necessary. Some residents refuse linen changes or removal of items from their rooms. The residents' rooms and bathrooms are cleaned daily. Staff provide education to residents but cannot force compliance when residents refuse cleaning, specifically referencing rooms requiring additional attention. Rooms identified as needing more attention are visited more frequently by housekeeping staff and the Housekeeping Director is responsible for ensuring compliance with environmental cleanliness and linen standards.

Based on observations, record review and interviews the facility's Quality Assessment and Assurance (QAA)/QAPI) committee demonstrate effective plan of action were implemented to correct identified quality deficiency in problem areas related to repeated deficient practice for F761-Lable/Store Drugs and Biologicals, F684-Quality of Care, F689-Free of Accident Hazards/Supervision/Devices and F867-QAPI/QAA Improvement Activities. As evidenced by: F761, F684, F689 and F867 were cited during a recertification survey ending 09/04/2024. There were 210 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's survey history revealed, during recertification conducted on September 01, 2024, through September 04, 2024, F761-Lable/Store Drugs and Biologicals, F684-Quality of Care, F689-Free of Accident Hazards/Supervision/Devices and F867-QAPI/QAA Improvement Activities. Review of the facility's policy and procedure titled Quality Assurance & Performance Improvement (QAPI) 06/10/2021 stated Policy: Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Interview on 01/28/2026 at 03:12 PM with the Administrator and Director of Nursing (DON) revealed: The QAPI/QAA team is composed of the Administrator, DON, Assistant Director of Nursing (ADON), Medical Director or attending physician, and members of the management team. Additional participants, include department heads and nursing unit staff are invited to participate as needed. The QAPI/QAA committee meets on the third Tuesday of every month. The primary purpose of the committee is to ensure regulatory compliance by identifying deficiencies, determining root causes, implementing corrective interventions, and monitoring outcomes to achieve and sustain compliance. The committee becomes aware of issues through strong interdepartmental communication, daily morning clinical meetings, and review of dashboard data. When concerns are identified, related issues are also reviewed, discussed during QAPI meetings, and addressed through Ad Hoc meetings when immediate action is required. Issues are prioritized based on severity and the potential risk for regulatory noncompliance, with higher-risk concerns addressed promptly. Corrective actions are communicated to staff, and leadership verifies implementation through ongoing feedback and staff-reported observations. Improvement is determined through audit results, staff and management feedback, visible practice changes, and evidence of sustained progress over time.

Based on observations, interviews and record review, the facility failed to secure confidential information for residents on two (East and J) out of three nursing stations as evidenced by: 1) Paperwork with residents/ medical information left visible and unattended at the J nursing station. 2) An unattended computer screen with resident information visible on the East nursing station. There were 210 residents residing in the facility at the time of survey. The findings included: 1) Observation on 01/25/2026 at 6:33 AM, revealed unattended medical information with residents' names at the J nursing station. On 01/25/2026 at 6:45 AM, Staff A, Overnight Supervisor Registered Nurse was apprised of the identified concern and stated, That posting is a privacy violation and will be removed. All information is to be kept private. The findings include: 1) On 01/27/2026 at 09:45 AM a staff member left the computer unattended at the East wing nursing station with a patients' information visible. Interview on 01/27/2026 at 12:32 PM with Staff V, LPN stated I have been a nurse supervisor for one year and work throughout all units in the facility. My understanding of Health Insurance Portability and Accountability Act (HIPAA) focuses on maintaining resident privacy and confidentiality. Examples include ensuring computer screens and medication carts are locked before stepping away and safeguarding all resident information from unauthorized access or disclosure. I consistently reinforce HIPAA education with staff during daily interactions; however, formal in-service training is primarily provided by the infection preventionist. HIPAA training is reinforced during daily morning huddles, with more in-depth discussions and updates conducted during weekly staff meetings. Interview on 01/28/2026 at 03:53 PM with Director of Nursing (DON) stated Regarding HIPAA, my understanding is that patient privacy and confidentiality must be maintained at all times. Computer screens must be closed or locked when not in use, and patient information at nursing stations should not be visible to unauthorized individuals. Staff should avoid discussing patient information aloud in public areas. Medication carts must remain closed, and computer screens should be locked before walking away. Staff are not permitted to leave computers unattended while logged in. Education and reinforcement of HIPAA and privacy practices are a collaborative effort between myself and the infection preventionist through ongoing training and in-service sessions. Review of the facility policy titled HIPPA Policy 11/27/2019 stated 1. Examples of violations include, but are not limited to:e. Leaving a secured application unattended while logged on.

Based on observations, interviews, and record review facility created an unsafe environment with potential accidents and hazards for one (Resident#94) out of two sampled smoking residents and all residents as evidenced by: 1) The facility's staff failed to provide an apron for Resident#94 while smoking. 2) Facility staff failed to remain vigilant while assigned to monitor to prevent elopement. 3) Facility staff failed to keep one out of six housekeeping carts locked while unattended. This deficient practice increased the risk of accidents and hazards that could have caused serious harm or injuries. There were seven residents listed as smokers on the J Unit and six housekeeping carts. The findings included: 1)Observation on 01/25/26 at 6:00 AM, Staff L, Monitor seated in a chair with head down and eyes closed near double doors at the end of The J hallway. Surveyor greeted Staff L, Monitor twice and staff did not move or respond. Surveyor greeted Staff L, Monitor again and Staff L, Monitor looked up. Interview on 01/25/26 at 6:05 AM, Staff L, Monitor stated, I am assigned to monitor during night shift to ensure residents don't elope through the double doors. Surveyor asked Staff L, Monitor How can residents be properly monitored while Staff L, Monitor is seated with eyes closed and head down and Staff L, Monitor replied, Sorry. On 01/25/26 at 8:10 AM Staff E, Registered Nurse (RN) was notified about identified concern stated, I monitor staff and they know what they are supposed to be doing. During an interview on 01/28/26 at 10:42 AM The Assistant Director of Nursing (ADON) revealed there is a monitor assigned overnight at the double doors in the J hallway to prevent residents from exiting the building. Further revealed the monitors are expected to sit by the door and remain awake. 2)Observation on 01/25/2026 at 6:52 AM, revealed a housekeeping cart with keys in the door. (photo evidence) On 01/25/2026 at 6:55 AM, Staff N, Housekeeping staff returned to cart and was notified about identified concern and stated, Sorry. I am supposed to keep the cart locked and the keys with me. During an interview on 01/28/2026 at 11:25 AM, The Housekeeping Director stated, The housekeeping carts should be locked when unattended and the keys are to be kept with housekeeping staff. 3. Observation on 01/28/26 at 9:30 AM, revealed Resident#94 smoking with no apron. Resident#94 was unable to verbalize answers to any questions. On 01/28/26 at 9:35 AM Staff J, Driver/ Monitor was asked by surveyor which residents require aprons stated, Residents listed dependent with apron. Record review of the smoking list kept in the smoking area revealed Resident#94 was listed as dependent and did not include apron.(photo evidence) Record review of a demographic sheet revealed Resident#94 was admitted on [DATE] and readmitted on [DATE] with diagnosis that include but not limited to: Metabolic Encephalopathy. Record review of an admission Minimum Data Set (MDS) reference dated 12/13/24 revealed Resident#94's Brief Interview for Mental Status was undetermined and used Tobacco. Record review of a care plan initiated on: 12/24/24 and revised on: 10/01/25 revealed Resident#94 was at risk for injury such as burn from cigarettes related to smoking practices, a dependent smoker, and is provided an apron with an interventions to: Provide smoking apron as needed. Record review of September and December 2025 Smoking Screens indicated Resident#94 required a smoking apron. Interview on 1/28/26 at 10:05 AM, The Social Services assistant was interviewed about the smoking screen completed in September and stated, Both smoking assessments for Resident#94 were incorrect. I don't know why the care plan was not updated. Also revealed the December smoking screen was completed by another staff member. During an interview on 01/28/26 at 11:06 AM, The Social Services Director stated, The care plans and screenings for Resident#94 are correct. The list kept outside in the smoking area was not updated correctly. The list will be updated. Record review of facility policy titled Smoking Policy no date revealed Policy: This facility shall establish and maintain safe resident smoking practices. Record review of facility policy titled Accidents and Supervision date implemented: 11/27/2017 Reviewed/Revised on 01/16/2019 revealed Policy: The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes:Identifying hazard(s) and risk(s)Evaluating and analyzing hazard(s) and risk(s)Implementing interventions to reduce hazard(s) and risk(s)Monitoring for effectiveness and modifying interventions when necessary

Based on observations, records reviewed, and interviews, the facility failed to properly position an indwelling urinary catheter tubing and drainage bags for two (Resident # 7 and Resident # 93) out of three sampled residents with an indwelling urinary catheter. Resident # 7's urinary catheter drainage bag was observed on the floor uncovered and drainage bag was on the floor, Resident #93's indwelling catheter tubing lay over the right-side bedside rail padding above the bladder, which prevented the flow of urine from the bladder and the drainage bag was in a privacy bag that touched the floor. These deficient practices increased the residents' risk for catheter-associated urinary tract infections and other serious medical issues. At the time of this survey, thirteen residents with indwelling urinary catheters resided in the facility.The findings include: Resident #7 Observation on 01/25/2026 at 6:33 AM revealed Resident #7 in bed the indwelling urinary catheter drainage bag was uncovered on the floor, the privacy bag was also noted on the floor. The resident reported that he had had the indwelling catheter for one week and did not know why the catheter bag was on the floor. (Photographic evidence). On 01/28/2026 at 6:00 AM, Resident #7 was observed in bed with eyes closed. The indwelling urinary catheter drainage noted in a privacy bag and touching the floor (Photographic evidence). Record review of Resident #7 clinical records revealed a re-admission to the facility on [DATE] and had an indwelling urinary catheter in place related to diagnosis of pressure ulcer of the sacral region, unstageable. Record review of Resident #7's physician orders revealed indwelling urinary catheter related orders dated 1/1/2026: Provide catheter care every shift and as needed. Monitor catheter every shift for signs and symptoms of infection or blockage. Check catheter stabilization device every shift and as needed. Cover the catheter drainage bag at all times Review of the Resident #7's Quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident did not have a catheter at that time and was participating in a bladder toileting program. Review of the resident #7's care plan (review start date 2/6/2026, completion date 1/21/2026) revealed: The resident has an indwelling urinary catheter and is at risk for urinary tract infection and other catheter-related complications. Interventions included: Ensure the catheter is attached to bedside drainage and that a closed drainage system remains intact, place the drainage bag in a privacy bag at all times, provide indwelling catheter care per facility protocol. Interview on 01/25/2026 at 06:43 AM Staff O, License practical nurse (LPN) revealed the indwelling catheter drainage bag should not be on the floor, indwelling catheter drainage bags are supposed to be attached to the side of the bed and should be covered. Interview on 01/25/2026 at 08:01AM, Staff P, Registered Nurse (RN) revealed she was the nurse assigned to Resident #7 the last time she observed Resident #7, the catheter drainage bag was anchored to the side of the bed inside a dignity (privacy) bag furthermore the resident had no history of removing the catheter or drainage bag. When shown photographic evidence Staff P, RN noted the placement of the catheter drainage not acceptable. Resident #93 Observation on 01/25/2026 at 1:39 PM, Resident #93 was awake in bed, the indwelling urinary catheter tubing contained dark red urine and positioned over the right-side bed rail padding and the drainage bag noted in a privacy bag was touching the floor (Photographic evidence). Observation on 01/26/2026 at 1:26 PM, revealed Resident # 93's indwelling urinary catheter tubing and dignity bag were touching the floor next to the bed. On 01/26/2026 at 2:04 PM, Staff D, Registered Nurse (RN) was made aware of the identified concern and stated, It should not be touching the floor for infection control. Record review of a demographic sheet revealed Resident # 93 was admitted on [DATE] and readmitted on [DATE] with diagnosis that include but not limited to: Gastrostomy status and pressure ulcer of sacral region. Record review of a quarterly Minimum Data Set (MDS) reference dated 11/21/25 revealed Resident # 93 Brief Interview of Mental Status (BIMS) score was undetermined, was dependent on all Activities of Daily Living had an indwelling catheter and a feeding tube. Record review of a care plan initiated on 10/16/2025 and revised on 12/04/2025 revealed Resident # 93 had an indwelling catheter and was at risk for Urinary Tract Infection (UTI) and other catheter related problems with an intervention to attach catheter to bedside drainage and ensure closed drainage system intact. Interview on 01/28/2026 at 10:40 AM, The Assistant Director of Nursing stated, The facility's protocol for caring for residents with an indwelling urinary catheter include ensuring tubing is not kinked and preventing tubing and bag from touching the floor to prevent infection. On 01/28/2026 at 11:31 AM an interview with Infection preventionist and Director of nursing revealed that an indwelling catheter drainage bag should not be placed on the floor and should be maintained inside a privacy bag. Interview on 01/28/2026 at 12:46 PM Staff Q, Certified Nurse Assistant (CNA) revealed an indwelling catheter drainage bag should not be placed on the floor and should be inside a privacy bag. Interview on 01/28/2026 at 12:55 PM Staff R, Certified Nurse Assistant (CNA) stated the urine collection bag should covered with a privacy bag and should not be touching the floor. On 01/28/2026 at 1:40 PM the photographic evidence of Resident #93's catheter tubing placement identified on 01/25/2026 was shown to the Infection Control Preventionist (ICP). The ICP acknowledged the concern and revealed the tubing should be below the bladder to prevent backflow which could cause a Urinary Tract Infection. Review of the policy titled Infection Control issued on 06/2020 revealed that it is the policy of the facility to ensure that the Infection Control Program is designed to prevent, identify, report, investigate, and control the spread of infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with State and Federal Regulations, and national guidelines.

Based on observations records reviewed and interviews, the facility's staff failed to follow medication administration procedure via Percutaneous Endoscopic Gastrostomy tube (PEG) in accordance with professional standards for one of one resident ( Resident # 93) observed for medication administration via PEG tube; as evidenced by staff did not clean the tip (port) and did not check the PEG tube for placement and patency before medication administration. This deficient practice can lead to severe, life-threatening complications for Resident #93. There were 19 residents with PEG tubes residing in the facility at the time of the survey. The findings included: Observation on 01/25/2026 at 1:29 PM of medication administration performed by Staff F, Licensed Practical Nurse (LPN) for Resident # 93 revealed Staff F, LPN verified the physician's orders in the Electronic Health Records performed hand hygiene using hand sanitizer and prepared two (2) Bromocriptine 2.5 milligrams (ml) tablets, crushed and placed the medication in a 30 ml (milliliter) cup and added water to dissolve the medication. Staff F, LPN entered Resident #93's room, provided privacy, explained procedure being performed to Resident # 93, placed tray with dissolved medication, cup with water and syringe on the overbed table, adjusted the bed height, performed hand hygiene using hand sanitizer and applied gloves. It was noted that the resident's enteral feeding pump was off and tubing disconnected and Staff F, LPN revealed the feeding was off because the resident had episodes of vomiting earlier in the morning. Staff F, LPN proceeded to open the peg tube valve port inserted the syringe, poured water in syringe but the water was not flowing; Staff F, LPN was noted squeezing and sliding her fingers along the tube to clear the tubing, but the water still was not flowing. Staff F, LPN then pushed the plunger into the syringe and pushed the water in, removed the plunger, poured the dissolved medication into the syringe but the contents in the syringe was not flowing freely. Staff F, LPN pushed the contents with the syringe's plunger removed plunger and added 30 ml water and pushed in the water with the plunger; removed the syringe and connected the tubing to the feeding pump. Staff F, LPN did not check the PEG tube placement, did not clean the valve port before administering the medications and did not clean the connector tip before connecting the feeding pump.Clinical records revealed Resident #93 was admitted to the facility on [DATE]. Clinical diagnoses include but not limited to: Aphasia following Cerebral Infarction, Dysphagia following Cerebral Infarction, Gastrostomy Status, Seizures, Parkinsonism, Respiratory Failure and Tracheostomy Status.Review of Resident # 93's Physician Order Summary Report for January 2026 included order dated 01/22/2026: Enteral Feed Order every shift Check peg tube for placement and patency every shift.Order dated 12/02/2025: Enteral Feed Order- every shift Flush Peg Tube With 30 ml of water Before and After Meds AdministrationOrder dated 12/02/2025: Enteral Feed Order- every shift [formula]1.5 Continuous Feeding at 55 ml/hr. (milliliters per hour) x 22 hrs. for a total of 1,210 ml infused; on at 12:00 PM, off at 10:00 AM.Bromocriptine Mesylate oral tablet 2.5 mg. Give 2 tablet via PEG-Tube every 6 hours related to other secondary Parkinsonism.Review of Resident # 93's care plan initiated 05/16/2025, Revision on: 07/24/2025 Target Date:11/19/2025 revealed: Focus- Resident #93 is enterally fed and is at risk for complications related to: tube feeding. Goal- will remain free of complications of tube feeding such as dehydration, nausea, vomiting, diarrhea, aspiration; signs /symptoms of infection and dislodgement over the next review date. Interventions-Check for tube placement and residual volume. Check patency and placement of peg tube every shift.Review of the resident's Quarterly Minimum Data Set (MDS) reference dated 11/21/25 revealed Resident # 93 Brief Interview of Mental Status (BIMS) score was undetermined, was dependent for all Activities of Daily Living and has a feeding tube.During an interview on 01/25/2026 at 2:25 PM with Staff F, LPN the identified concerns were discussed including the facility's protocol for administering medications via PEG. Staff F, LPN stated: I missed steps and did not check the tube placement; I only checked for tenderness and distention with my hands.During an interview on 01/28/2026 at 1:30 PM, the Director of Nursing (DON) and the Infection Control Preventionist (ICP) were apprised of the identified concerns. The ICP and DON explained that staff are expected to clean tip and valve connector before use and check the PEG tube placement before administering medications. Review of the facility's policy titled Medication Administration via Enteral Tube; Implemented 2020 indicated:Policy:It is the policy of this facility to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines.10. Procedure:h. Enteral tube placement must be verified prior to administering any fluids or medication.

Based on observations, records review and interviews, the facility failed to provide adequate respiratory care and services for one (Resident #1) out of two sampled tracheostomy residents as evidenced by an observation of oxygen being delivered at a rate below the prescribed level for Resident #1. There were seven residents with a tracheostomy residing in the facility at the time of survey. The findings include. During a Tracheostomy (trach) care observation on 01/27/26 at 11:14 AM Resident #1's oxygen was in progress at a rate of four Liters per minute (L/min) (photo evidence). Surveyor notified Staff I, Respiratory Therapist (RT) and Staff I, RT revealed the order is for five (5) L/min. Staff I, RT then adjusted the oxygen concentrator to prescribed rate. On 01/27/2026 at 11:57 AM Staff D, Registered Nurse (RN) stated: The order for oxygen is 5 L/min. I do rounds frequently. This morning when I came on shift it was at 5 L/min. On 01/27/2026 at 12:19 PM Staff H, Certified Nursing Assistant (CNA) stated, I never touch residents' oxygen machines, that is not my responsibility. Record review of a demographic sheet revealed Resident #1 had an admission date of 11/20/2025 with diagnosis that included: Tracheostomy and Acute and Chronic Respiratory failure with hypoxia. Record review of a Quarterly Minimum data Set (MDS) reference dated 12/5/25 revealed Resident #1's Brief interview of mental status score was undetermined, dependent for all activities of daily living, received oxygen therapy, suctioning, and trach care. Record review of a care plan initiated on 07/29/2025 and revised on 07/29/2025 revealed Resident #1 had a tracheostomy and interventions that included: administer medication and or oxygen as ordered. Record review of a physician's order sheet revealed Resident #1 had an order dated 1/15/26 directions: Trach: Oxygen 5L/Min continuous via trach collar, humidified (Concentrator with compressor) Maintain oxygen saturation over 92% every shift Record review of a policy titled, Tracheostomy Care dated 3/2020 reviewed 8/2024 revealed Policy: The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. Record review of a policy titled, Physician Services date: 3/1/2021 revealed intent: It is the policy of the facility to ensure Physician Services are in accordance with State and Federal regulations. Procedure: 6. All physician orders must be followed as prescribed, and if not followed, the reason must be recorded on the resident's medical record during that shift.

Based on observations records reviewed and interviews the facility failed to ensure drugs and biologicals are securely stored in accordance with professional standards for one (J Wing Cart 2) out of four medication carts reviewed as evidenced by medication cart two on the J wing was noted unlocked and unattended 2) Facility staff left medications unattended at bedside for Resident #50. The findings included: Observation on 01/25/2026 at 6:35 AM, revealed medication inside a transparent cup left unattended on the side table next to Resident # 50. (photo evidence)1) On 01/25/2026 6:38 AM Staff B, Registered Nurse (RN) entered the room and was asked by surveyor if medication can be left at the bedside unattended. Staff B, RN replied, I left the medication to get a gown. Further stated, Medications are stored in the medication cart to protect residents.2) Observation on 01/26/2026 at 9:38 AM, an unlocked, unattended medication cart (photo evidence). On 01/26/2026 at 9:43 AM Staff D, RN exited a room and was asked about the unlocked cart and stated, I left it open because I was helping a resident and was not far from the cart. We are supposed to keep the medication cart locked when away from the cart.During an interview on 01/28/2026 at 10:43 AM, The Assistant Director of Nursing stated, Medications are to be stored in a secure locked cart or medication room for safety of residents. Record review of facility's policy and procedure titled Labeling of Medications Storage of Drugs and Biologicals issued 3/2020 revealed Policy: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations.

Based on observations, interviews and record review, the facility failed to provide a safe environment for one (Resident #2) out of three residents sampled as evidenced by observations of an electric water kettle sitting on the bedside table and plugged in the electrical receptacle next to the bed. There were 211 residents present in the facility at the time of the survey. The findings included: Record review of the facility's policy titled Accidents and Incidents (dated 3/2021) documented: Policy-It is the policy of the facility to report Accidents and Incidents in accordance to State and Federal regulations; Procedure: The facility will provide and environment that is free from accident hazards over which the facility has control and provides supervision to each resident to prevent avoidable accidents. This includes: a) Identifying hazards and risks, b) Evaluating and analyzing hazards and risks, c) Implementing interventions to reduce hazards and risks and d) Monitoring for effectiveness and modifying interventions when necessary. Observation and interview of Resident #2 on 6/30/25 at 7:35 AM, revealed the resident sitting in a chair in his room, watching television. On the bedside table was an electric water kettle, instant coffee and coffee creamer. The electric water kettle was plugged in the electrical receptacle next to the bed. He stated, I have it because they won't make me coffee when I want it and I make my own. Please don't tell them that I have it. Resident #2 had a roommate. Photographic evidence submitted. Review of the Demographic Face Sheet for Resident #2 documented the resident was admitted to the facility on [DATE] with diagnoses to include congestive heart failure, hypertension and major depressive disorder. Review of the Minimum Data Set (MDS) admission Assessment for Resident #2 dated 4/17/2025 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 14 out of 15 indicating no cognitive impairment and able to make own decisions. The resident required partial moderate to substantial/maximal assistance for ADLs (Activities of Daily Living). A second observation of Resident #2 on 6/30/25 at 12:15 PM, revealed the resident sitting in a chair in his room, eating lunch. On the bedside table was an electric water kettle, instant coffee and coffee creamer. The electric water kettle was plugged in the electrical receptacle next to the bed. On 6/30/2025 at 1:38 PM, interview with the Director of Nursing (DON). She stated, He tends to buy his own products. He had a coffee pot before when the staff did rounds and it was removed. On 6/30/2025 at 2:58 PM, interview with the Social Services Director. He stated, This is the second time with the coffee maker. The first time was an actual coffee maker and the staff removed it.

Based on observations, interviews and record review, the facility failed to provide a well-balanced diet to meet special dietary needs for one diabetic (Resident #1) out of three residents sampled. There were 40 diabetic residents out of the 211 residents present in the facility at the time of the survey. The findings included: Record review of the facility's policy titled Nutrition and Hydration (revised 6/2021) documented: Policy-Residents within the facility will maintain adequate parameters of nutritional and hydration status, to the extent possible, to ensure each resident is able to maintain the highest practicable level of well-being; Policy Explanation and Compliance Guidelines: 1) The facility will: a) Provide nutritional and hydration care and services to each resident, consistent with the resident's comprehensive assessment, b) Recognize, evaluate and address the needs of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration, c) Provide a therapeutic diet taking into account the resident's clinical condition and preferences and d) Resident's diet order is communicated to the dietary department by completing a dietary communication slip and 2) Based on the resident's comprehensive assessment, the facility will ensure each resident: c) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. Observation and interview of Resident #1 on 6/30/25 at 7:43 AM, revealed the resident sitting in a chair in his room and received his breakfast tray. The breakfast tray consisted of: Boiled egg (1), Oatmeal (1 bowl), Toast (2 slices), Regular Sugar (3 packets), Regular grape jelly (1 packet), Coffee (1 cup). The tray did not include a meat, a choice of Vitamin C juice, sugar substitutes and sugar-free jelly. The resident revealed via a Spanish translator that he eats what his roommate tells him to eat on the food tray because he is diabetic. He doesn't use the regular sugar or regular jelly. They don't send him a diabetic sugar or jelly on his food tray. Photographic evidence submitted. Review of the Breakfast Diet Card for Resident #1 documented the resident consumed a Regular, LCS (Low Concentrated Sweets), NAS (No Added Salt) diet; Boiled Egg no shell or scrambled, Sausage or ham. To be served: Choice of Vitamin C juice (6 ounces), Oatmeal or Frosted Flakes Cereal (1/2 cup or ¾ cup), Scrambled eggs, Crispy bacon Strip (1 strip), Biscuit (1 each), Jelly (1 packet), Margarine (1 each) Whole milk (8 ounces), Coffee/Hot tea (6 ounces), Sugar, Pepper (1 each). Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of diabetes mellitus, hypertension, hemiplegia, protein-calorie malnutrition and hyperlipidemia. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident #1 documented the resident's Mental Status (BIMS) Summary Score was 11, indicating mild cognitive impairment and able to make his needs known. The resident required partial to moderate to substantial/maximal assistance for ADLs (activities daily living) and supervision or touching assistance for eating. A therapeutic diet was prescribed for the resident. Review of the Physician's Order Sheets (POS) dated May 2025 and June 2025 for Resident #1 documented the resident was on a LCS (Low Concentrated Sweets), NAS (No Added Salt), Regular texture and Thin consistency. The resident receives Insulin Aspart Subcutaneous Solution Pen-injector 100 unit/ml (milliliters) inject 4 unit subcutaneously before meals related to diabetes mellitus with hyperglycemia, Insulin Aspart Subcutaneous Solution Pen-injector 100 unit/ml inject as per sliding scale subcutaneously before meals for hyperglycemia related to diabetes mellitus with hyperglycemia and Insulin Glargine Solution 100 unit/ml inject 6 unit subcutaneously every 12 hours related to diabetes mellitus. Review of the Nutrition care plan (written 2/05/2025) for Resident #1 documented the following: Focus: Resident is at risk for nutritional and or hydration deficits as evidenced by hyperglycemia and hemiplegia; Goal: Resident will show no s/s (signs and symptoms) of dehydration (dry skin, dry cracked lips, concentrated urine, increased confusion, abnormal labs that may indicate dehydration) thru NRD (next review date) x (times) 90D (90 days); Interventions: LCS, NAS diet, Regular texture and Thin consistency; Offer meal substitute as needed/requested; Review/counsel on prescribed diet, including any negative outcomes of non-adherence as applicable. A second observation of Resident #1 on 6/30/25 at 12:14 PM, revealed the resident sitting in a chair in his room, eating lunch. The lunch tray consisted of: Black beans, Rice, Chopped Baked Chicken, Unfrosted Banana Cake and Orange Drink. The tray did not include navy bean soup, buttered carrots or any vegetable, coffee or tea and sugar substitutes. Review of the Lunch Diet Card for Resident #1 documented the resident consumed a Regular, LCS (Low Concentrated Sweets), NAS (No Added Salt) diet. To be served: Navy Bean Soup (6 oz. ladle), Baked Chicken (3 ounces protein), Rice/Arroz (1/2 cup), Buttered Carrots (#8 scoop = ½ cup), Banana Cake (1 piece), Coffee/Tea (6 ounces), Sugar, Pepper (1 each). Review of the facility's Weekly Four Cycle Menu LCS/NAS diet documented the following: 1) Week 3 on Monday, 6/30/2025 residents received at breakfast: Choice of Vitamin C juice, Oatmeal or Frosted Flakes Cereal, Scrambled eggs, Crispy bacon Strip, Biscuit, Diet Jelly, Margarine, Whole milk, Coffee/Hot tea, Sugar Substitute and Pepper and 2) Week 3 on Monday, 6/30/2025 residents received at lunch: Navy Bean Soup, Baked Chicken, Rice/Arroz, Buttered Carrots, Unfrosted Banana Cake, Coffee/Tea, Sugar Substitute and Pepper. Review of Food and Beverage Preferences for Resident #1 dated 6/09/25 documented the resident disliked pancakes, desserts and sweets of any kind and no rice. On 6/30/2025 at 3:22 PM, interview with the Diet Technician (DT). She stated, LCS/NAS Regular diet with thin consistency. He is a diabetic. Yes, the meal ticket says LCS/NAS diet. We have [sugar substitute] and have diabetic jelly for diabetics. On 6/30/2025 at 3:46 PM, interview with the Dietary Manager. He stated, He had oatmeal, boiled egg, coffee, with regular sugar and regular jelly. I have diabetic jelly and [sugar substitute] for diabetics. He should not have gotten the regular sugar and jelly for breakfast. For lunch, I used substitute for navy bean soup which was black bean soup and for buttered carrots substituted peas. He should have had peas on his plate. Review of the Facility Assessment, updated 2/29/2024, date reviewed with QAPI Committee 2/29/2024 documented the facility has a diverse patient population and the Nutrition department provided individualized dietary requirements, liberal diets, specialized diets, tube feeding, cultural or ethnic dietary needs.

Based on observations, interviews and record review, the facility failed to ensure that menus were followed for nutritional adequacy to meet special dietary needs for one diabetic (Resident #1) out of three residents sampled. There were 40 diabetic residents out of the 211 residents present in the facility at the time of the survey. The findings included: Observation and interview of Resident #1 on 6/30/25 at 7:43 AM, revealed the resident sitting in a chair in his room and received his breakfast tray. The breakfast tray consisted of: Boiled egg (1), Oatmeal (1 bowl), Toast (2 slices), Regular Sugar (3 packets), Regular grape jelly (1 packet), Coffee (1 cup). The tray did not include a meat, a choice of Vitamin C juice, sugar substitutes and sugar-free jelly. The resident revealed via a Spanish translator that he eats what his roommate tells him to eat on the food tray because he is diabetic. He doesn't use the regular sugar or regular jelly. They don't send him a diabetic sugar or jelly on his food tray. Photographic evidence submitted. Review of the Breakfast Diet Card for Resident #1 documented the resident consumed a Regular, LCS (Low Concentrated Sweets), NAS (No Added Salt) diet; Boiled Egg No shell or scrambled, Sausage or ham. To be served: Choice of Vitamin C juice (6 ounces), Oatmeal or Frosted Flakes Cereal (1/2 cup or ¾ cup), Scrambled eggs, Crispy bacon Strip (1 strip), Biscuit (1 each), Jelly (1 packet), Margarine (1 each) Whole milk (8 ounces), Coffee/Hot tea (6 ounces), Sugar, Pepper (1 each). Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of diabetes mellitus, hypertension, hemiplegia, protein-calorie malnutrition and hyperlipidemia. Review of the Minimum Data Service (MDS) Quarterly assessment dated [DATE] for Resident #1 documented the resident's Mental Status (BIMS) Summary Score was 11, indicating mild cognitive impairment and able to make his needs known. The resident required partial to moderate to substantial/maximal assistance for ADLs (activities daily living) and supervision or touching assistance for eating. A therapeutic diet was prescribed for the resident. Review of the Physician's Order Sheets (POS) dated May 2025 and June 2025 for Resident #1 documented the resident was on a LCS (Low Concentrated Sweets), NAS (No Added Salt), Regular texture and Thin consistency. The resident receives Insulin Aspart Subcutaneous Solution Pen-injector 100 unit/ml (milliliters) inject 4 unit subcutaneously before meals related to diabetes mellitus with hyperglycemia, Insulin Aspart Subcutaneous Solution Pen-injector 100 unit/ml inject as per sliding scale subcutaneously before meals for hyperglycemia related to diabetes mellitus with hyperglycemia and Insulin Glargine Solution 100 unit/ml inject 6 unit subcutaneously every 12 hours related to diabetes mellitus. Review of the Nutrition care plan (written 2/05/2025) for Resident #1 documented the following: Focus: Resident is at risk for nutritional and or hydration deficits as evidenced by hyperglycemia and hemiplegia; Goal: Resident will show no s/s (signs and symptoms) of dehydration (dry skin, dry cracked lips, concentrated urine, increased confusion, abnormal labs that may indicate dehydration) thru NRD (next review date) x (times) 90D (90 days); Interventions: LCS, NAS diet, Regular texture and Thin consistency; Offer meal substitute as needed/requested; Review/counsel on prescribed diet, including any negative outcomes of non-adherence as applicable. A second observation of Resident #1 on 6/30/25 at 12:14 PM, revealed the resident sitting in a chair in his room, eating lunch. The lunch tray consisted of: Black beans, Rice, Chopped Baked Chicken, Unfrosted Banana Cake and Orange Drink. The tray did not include navy bean soup, buttered carrots or any vegetable, coffee or tea and sugar substitutes. Review of the Lunch Diet Card for Resident #1 documented the resident consumed a Regular, LCS (Low Concentrated Sweets), NAS (No Added Salt) diet. To be served: Navy Bean Soup (6 oz. ladle), Baked Chicken (3 ounces protein), Rice/Arroz (1/2 cup), Buttered Carrots (#8 scoop = ½ cup), Banana Cake (1 piece), Coffee/Tea (6 ounces), Sugar, Pepper (1 each). Review of the facility's Weekly Four Cycle Menu LCS/NAS diet documented the following: 1) Week 3 on Monday, 6/30/2025 residents received at breakfast: Choice of Vitamin C juice, Oatmeal or Frosted Flakes Cereal, Scrambled eggs, Crispy bacon Strip, Biscuit, Diet Jelly, Margarine, Whole milk, Coffee/Hot tea, Sugar Substitute and Pepper and 2) Week 3 on Monday, 6/30/2025 residents received at lunch: Navy Bean Soup, Baked Chicken, Rice/Arroz, Buttered Carrots, Unfrosted Banana Cake, Coffee/Tea, Sugar Substitute and Pepper. Review of Food and Beverage Preferences for Resident #1 dated 6/09/25 documented the resident disliked pancakes, desserts and sweets of any kind and no rice. On 6/30/2025 at 3:22 PM, interview with the Diet Technician (DT). She stated, LCS/NAS Regular diet with thin consistency. He is a diabetic. Yes, the meal ticket says LCS/NAS diet. We have [sugar substitute] and have diabetic jelly for diabetics. On 6/30/2025 at 3:46 PM, interview with the Dietary Manager. He stated, He had oatmeal, boiled egg, coffee, with regular sugar and regular jelly. I have diabetic jelly and [sugar substitute] for diabetics. He should not have gotten the regular sugar and jelly for breakfast. For lunch, I used substitute for navy bean soup which was black bean soup and for buttered carrots substituted peas. He should have had peas on his plate. Review of the Menu Substitution Log dated 6/30/25 documented the lunch planned menu items were substituted. The planned menu item was Buttered Carrots and was substituted for peas and the planned menu item for dessert was Banana Cake and was substituted for Yellow cake, no frosting. Review of the Facility Assessment, updated 2/29/2024, date reviewed with QAPI Committee 2/29/2024 documented the facility has a diverse patient population and the Nutrition department provided individualized dietary requirements, liberal diets, specialized diets, tube feeding, cultural or ethnic dietary needs.

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 F689 Accidents Hazards and F803 Menus Meet Resident Needs and Followed. These deficient practices have the potential to affect 211 residents residing in the facility at the time of the survey. The findings included: Record review of Quality Assurance and Performance Improvement (QAPI) policy and procedure (issue date June 2021). The purpose of the committees is to review and analyze facility related data, evaluate improvement plans effectiveness and direct appropriate actions for the facility response. Systems failures and/or in-depth analysis of processes are addressed through development of a QAPI. QAPI requires a systematic review of data, identification of the root cause(s) of the systems failure and implementation of corrective actions. Review of the facility's survey history revealed, during a recertification survey with exit dated August 1, 2024, F689 Accidents Hazards and F803 Menus Meet Resident Needs and Followed were cited. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 4/22/25, 5/20/25 and 6/24/25: documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. Interview with the Administrator on 06/30/2025 at 5:07 PM. She revealed the QAPI (Quality Assurance and Performance Improvement) meetings are held on the third Tuesday of each month or as needed. She stated that QAPI committee members are Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Infection Preventionist, Risk Manager, Social Services Director, Dietary Manager, Maintenance Director, Human Resources, Activity Director, Restorative, Housekeeping/Laundry Supervisor, Registered Dietitian, Business Office Manager, Unit Managers and Pharmacy. She stated, The purpose of the QAPI committee is to ensure all departments are in compliance with policies and procedures and regulatory statures.

Based on observations, interviews, record review, the facility failed to protect the resident's right to be free from neglect as evidence by; Resident #1 a vulnerable resident with exit seeking behaviors who voiced intent to leave the facility and refused to sign an Against Medical Advice (AMA) was not adequately supervised and monitored by the facility's staff who did not see the resident exit the facility. Resident #1 was found decomposed in a locked closet 12 days after the facility documented he left the facility AMA. Refer to F607, F689 and F835 The findings include: Observation on 09/04/24 at 9:36 AM with the [NAME] President of Operations and the Regional Director of Operations of the space within which Resident #1 was found revealed the space was located in the rear dining room that is used for activities located in the J Unit, cameras were observed in the dining area. The door to the closet where Resident # 1 was found had a Key Entry Lever Handle Lock; there were several boxes and a working toilet that had boxes stacked on it. The Regional Director of Operations revealed the room was previously used as a shower room and is now storage closet. A tour of the area outside the dining/activities area revealed the two emergency exit doors had alarms that required a code prior to opening surveillance cameras were noted on the building's exterior. When asked if the cameras were working The [NAME] President of Operations revealed the cameras were not working and were left in place by the previous owner. Review of Resident # 1's admission Records revealed an admitted [DATE]. The contacts information documentation indicated the resident as Self, the emergency contact #1 listed daughter, #2 Granddaughter and contact information listed for two sisters. Review of the clinical records revealed diagnoses that included but not limited to: Altered Mental Status, Cognitive Communication Deficit, Cerebral Infarction, Difficulty in Walking and Diabetes Mellitus. Review of Resident #1's August 2024 Physician's Order Sheets and Medication Administration Records revealed the resident was receiving medications that included but not limited to Lorazepam Tablet 0.5 mg 1 tablet by mouth two times a day for anxiety; Seroquel Oral Tablet 100 mg 1 tablet by mouth at bedtime for Agitation related to altered mental status. There was an order for Psych consult for diagnosis of agitation with revision dated 8/18/2024 that according to the Director of Nursing the resident did not receive because he was no longer in the facility. Review of Resident #1' Care Plans initiated 08/20/2024 Revision on: 08/28/2024 revealed Resident #1 is at risk for falls related to Unsteady gait and Vision impairment; Goal: Resident will be free of fall related injuries by next review date. Interventions: .Check at frequent intervals to monitor for unsafe actions and intervene promptly. Focus- risk for further alteration; in neurological functioning related to history of Cardiovascular Attack (Stroke) and Cerebrovascular Disease.; Date Initiated: 08/21/2024. Revision on: 08/28/2024. Risk for complications of abnormal blood sugar related to diagnosis of Diabetes Mellitus date initiated: 08/21/2024, Revision on: 08/28/2024. Review of Resident #1's 5- Day Minimum Data Set (MDS) dated [DATE] indicated the resident vision is impaired, Brief Interview of Mental Status Score (BIMS) documented 12 out of 15 to suggest Resident #1 was moderately impaired cognitively. Had wandering behavior that occurred 1 to 3 days; Required supervision or touching assistance for eating, oral hygiene; substantial/maximal assistance for toileting, lower body dressing; partial/moderate assistance for upper body dressing; Frequently incontinent. The resident was receiving Antipsychotic, Antianxiety and Antiplatelet medications. No wander/elopement alarms used. Review of Resident # 1's Elopement Risk Assessment/Evaluation dated 8/21/24 completed and documented by the DON revealed an at-risk score of 11.0 meaning the resident was a high risk for elopement. Resident #1 was being monitored for behaviors since his admission on 08/14 /24 until; the behavior monitoring sheets documentation revealed on 8/17/24 during the day shift he had behaviors and was given food, on 8/20/24 he had behaviors during the night shift and was given food, he had behaviors during the day shift on 08/22/24 which documented refer to progress note. Review of the progress notes written by Registered Nurse (RN); Staff D dated 08/22/24 time stamped 15:50 documented: Around 1:00 PM resident noted as agitated requesting to leave the facility. When asked why, resident stated that he just did not want to be here anymore. Resident noted as self-responsible, made supervisor aware. Teaching provided regarding a facilitated transfer and supervisor called family but no answer. Resident refused and stated that he was leaving. Teaching provided regarding risks. Presented AMA however resident refused to sign. Resident then left facility alert and oriented in no distress. Will make another attempt to inform family. Review of the Discharge Without Physician's Approval Form Dated 8/22/24 revealed the resident had not signed above the line that indicated Signature of Resident the above the date line was dated 8-22-24. The Licensed Practical Nurse Unit Manager for the 7:00 AM to 3:00 PM shift confirmed it was his signature that was noted below the blank resident signature line. Review of Narrative Note written by the Assistant Director of Nursing (ADON) revealed; (General) dated 8/22/2024 timestamped 20:20: Call placed to [local community-based agency] for wellness check, spoke to [representative for the community based agency] who stated only local police do wellness checks however would document call. [local police department] was contacted for a wellness check and an address was provided. Review of Narrative note written by the ADON dated 8/23/2024 time stamped 12:44 documented: Resident daughter and granddaughter arrived at the facility, no concerns voiced however stated that the resident does not like to stay in one place for a long period of time and is violent and agitated at times. Family thanked staff for contacting [local community-based agency] and [local law enforcement] for the wellness check. Review of the facility's ABUSE LOG for August 2024 revealed, Resident #1 was listed on the abuse log for neglect on 8/22/24 related to Resident #1 and was unsubstantiated; Date 8/26/24; [Local community-based agency] called-8/22/24; Accepted/Rejected-Rejected; Allegations-Neglect; 5-Day Federal-9/02/24; Comments-Unsubstantiated. The facility's ELOPEMENT INCIDENT LOG for August 2024 had no incidents of elopements. Review of the Agency for Healthcare Administration (AHCA) Immediate Report dated 09/03/2024 included but not limited to: Date of Incident: 08/22/2024 13:10; Type of Incident-Neglect; Notified: Resident representative, Law Enforcement, Abuse Registry; Description of Incident: On 8/26/24 at 11:00 AM, [sister] and her daughter, visited the facility and spoke with [Administrator] and [Director of Nursing), stating they feel Memorial Regional Hospital was negligent for not diagnosing and notifying facility that her brother has dementia. They are upset that resident chose to leave the facility against medical advice on 8/22/2024 and went out into the streets instead of contacting them (written by Licensed Practical Nurse (LPN) Supervisor 8/26/2024 1:24:20 PM). On 8/22/2024, [Resident #1] left the facility against medical advice. Resident was encouraged to stay and complete his stay or to wait for his family to be discharged but refused and said he is fine, doesn't need to be here and that he takes care of himself. Resident was alert and oriented, voiced no safety concerns, complaints, concerns or change in his behavior at the time of his leaving AMA. Resident's family was notified. A call was placed to [local community-based agency] to notify resident left AMA to request a wellness check since resident left facility alone and would not wait for family. [Local community-based agency] stated they would record the call but that only law enforcement does wellness checks. Law enforcement was notified. Law enforcement stated resident was not at his last known address and was not at any area hospital During an interview on 9/04/24 at 10:46 AM the 7:00 AM to 3:00 PM Licensed Practical Nurse (LPN) Nurse Manager revealed; Resident #1 was sitting in a wheelchair on the day he left. The resident was anxious and restless. He was Creole speaking and spoke a little English. He was assessed and he wanted to leave the facility. We educate the patient and tell him the risks of him leaving. He was still restless, would stand up in the chair and re-directed him. I went to the morning meeting, when I came back I saw the nurse, [Staff D, RN] talking to the resident trying to redirect him. We spoke to him, and he didn't want to accept what we were trying to tell him. I looked in the [computer program] to see if the resident was self-responsible and I noted that he was, I let the DON know. We presented to the resident the AMA documentation, educated him on it and he refused to sign it, and he was anxious. I left him with the nurse. He had anxious behavior the day he left. He would go to different rooms and had exit seeking behaviors. The Nurse Manager was asked if he saw Resident #1 leaving the facility and if anyone escorted the resident from the facility. He stated: I didn't see him walk out the building. When I came to his room, his belongings were still in his room. The nurse [Staff D] didn't tell everybody that the patient went AMA. The staff was asking about the resident. The LPN Nurse Manager was asked to explain the facility's policy and procedure when a resident is being discharged , he explained: When a resident is being discharged and the resident is self-responsible, education is given by the nurse who is in charge. If they leave without medical advice, the medication will not go with them. I am not sure if the family was called when the resident was anxious. According to this resident, he wanted to go home. Vitals were stable. He was given food. He was in a wheelchair, but he could walk. The Administrator was notified by the nurse. I am not sure if the Administrator went to talk to the resident. The Certified Nursing Assistant (CNAs) assigned to the resident was providing care to another resident. We let the doctor know, let the family know, we give them the paperwork. I think the nurse called the doctor. I don't know what the doctor say. He was anxious but not in an aggressive way. I was made aware he went AMA after lunch around 1:00 PM. She didn't tell me [Staff D] right away that the resident went AMA. The Nurse Manager was asked if Resident #1 ate lunch that day and where did the resident usually eat his lunch. The Nurse manager stated: He would eat lunch in his room or in the hallway. The nurse manager was asked how he came to the conclusion that Resident # 1 was AMA if no one saw the resident exit the facility and may just be missing, because his belongings were still in his room. He revealed he did not see the resident leave the facility. During an interview on 09/04/24 at 11:26 AM the Resident # 1's assigned Certified Nursing Assistant (CNA), Staff B on the day of the incident reported he spoke a little bit of English but mostly spoke Creole. On the day of the incident at first he was in bed, afterwards he was cleaned and transferred to the wheelchair. He was in the hallway close to the nurses' station. In the morning during her rounds, he told her he wanted leave wanted to go home. Staff B stated: I expressed to my supervisor, [Staff A]. They went to talk to him [Staff A and Staff D]. I was moving about going to see about my other residents. This was my second time working with him on that day. He was very anxious, he would go from to bed, walking opening doors, by the exit doors. The nurse knew he was going from room to room. He would stand by the exit door right outside of his room. I only work here three days a week. He was combative and would argue with you. I would say to him come back to your room, if I saw him going to another room. Once we let our supervisor know if we see the resident wandering. I wasn't informed that he went AMA. When I left on my shift at 3:00 PM, he was in his wheelchair on the floor. I came back to work on the following Tuesday, I was made aware he was missing. During an interview on 9/04/24 at 1:19 PM the Nursing Home Administrator (NHA) reported after 1:00 PM on 8/22/2024 she was alerted that a resident was missing. We started looking for the resident in the building and out of the building. Some of us went driving around. Code green was called and that means someone is missing. A few minutes after we had gone driving around, [Staff A] called me and told me that he wasn't missing but he left AMA. He was dealing with the nurse and the resident when he said he wanted to leave, and he refused to sign the AMA form. When he told me it wasn't an elopement, and we went back to the building. The weather was bad, and I asked [ Staff A] did he say where he was going. The NHA was asked if anyone escorted the resident out of the building. She stated: Nobody escorted him out of the building, and we didn't know which way he went. Since it was bad weather, we called [local community-based agency] to do a wellness check and the family house was nearby. [Local community-based agency] told us they don't do wellness checks anymore and to call [local law enforcement] and we did. [Law enforcement] went to the address (niece), and he wasn't there. When the police went to the house they decided to file a missing person report. Since the facility became aware a missing person report had been filed with the police by the family after the wellness check was completed and the resident was not located. The NHA reported staff checked both inside and outside of the facility and when asked how they were able to confirm all area were checked within the facility she did not provide an answer. The NHA was asked why they did not continue searching in the facility every day and open all doors in the facility, no answer was provided. The NHA stated all hospitals were checked and areas close to the facility. The NHA was asked if they called the police to get any updates an if she was positive all areas were checked and if anyone had considered looking in that closet and asking for a key to open it. She stated she never thought of that. The NHA was asked if no one heard sounds from the closet or smelled anything while activities were being done in that area she said no. The NHA acknowledged she was unable to confirm if a thorough search was completed within the facility on 08/22/2024. We wanted to keep looking for him so some of use kept looking him, driving around the area. The next day on the 23 rd the daughter and the granddaughter came to the building to meet with me, [DON and ADON]. The daughter said he likes to walk the street and live on the street. His usual spot is by [local hospital]. We called the police that we had spoken to and gave them the information so they could look as well . On 8/26/24 the following Monday, the sister and the niece came to the building, asking questions regarding the situation me and (DON). The niece said he had dementia; we checked the chart and there was no documentation in our chart or the hospital chart that he had dementia. She said she was going to talk to the hospital because that was neglectful to not use that as a diagnosis. We did a neglect report on 8/26/24 and we unsubstantiated it. He was alert and oriented times three on our chart and the hospital's chart. I completed the 5-day report on yesterday. On 9/02/24, I got a call from [DON] around 8:30 AM that they found a body in the closet. Somebody was saying that there was a bad odor. The maintenance assistant started looking in the vents and rooms and couldn't find the smell. He had housekeeping come and open the door for him and he found the body was decomposed. [DON] called me, and I came straight over. The cops were here, the area was closed off and we couldn't go back there. At that point, the detective was asking questions and interviewing the staff. The medical examiner took the body and when the detective was done we started cleaning the area. The NHA was asked if she should have been notified that the resident was agitated and wants to leave AMA and be notified of all AMAs, she stated: Sometimes they notify me if a resident leaves AMA. They are supposed to educate the resident about what AMA means. The NHA was as asked if it was unusual for a resident to leave without taking their belongings. She stated: I went in his room and his things were there. We have had some AMAs, and they have left their things because they had too many things. The NHA was asked if she was sure everywhere in the facility was checked including that specific closet. She stated: The DON said he checked that closet, but it was locked. It was an old shower room, and we had been using it as a storage room for boxes and papers. I wasn't aware that it could lock from the inside. When asked why they did not get the keys so the door could be unlocked and checked she did not respond. On 9/04/24 at 1:49 PM, the Director of Nursing (DON) revealed on the afternoon of the incident someone told him that a resident was missing, he went to look for the resident in the area. When he returned to the facility he was told the resident went out AMA. Late that afternoon, it was about to rain, he asked the Administrator and the ADON, if a wellness check needed to be done. The ADON called [local community-based agency], and they told her they do not do a wellness checks anymore and to call the police. The police was called, and they told the police what happened. The DON reported he went back out to search for the resident and did not find the resident. The police asked should we file a missing person's report, and I said no because he filed an AMA. [Staff A], LPN the Supervisor and [Staff D], RN the nurse for the resident signed on the AMA form. We had procedures in place for elopement and AMA. The DON was asked if he was positive all areas in the facility was checked. He reported everywhere was checked. The DON reported he did not know the resident was agitated and wanted to leave. During an interview via telephone on 09/05/2024 at 1:16 PM, the Medical Director was asked if he was notified of Resident #1 wanting to leave the facility AMA. He stated, I was not notified. I became aware of the incident while I was in the facility on Thursday (08/22/2024) that afternoon around 2:00 PM to 3:00 PM and was told they were looking for a missing resident. He reported, if a resident wishes to leave AMA and is alert the resident will need to sign the AMA form, if the resident is unable to sign and they have a proxy the proxy will need to sign, if the proxy cannot be located to sign a guardian will be appointed to sign. When a Resident is agitated even if they are responsible for themselves, the staff cannot let that resident leave AMA. An agitated resident should be sent to the hospital; and the family or emergency contacts should be notified. Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and Procedure revision date was on 10/2022, 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 Transfer and Discharge (including AMA. Date Implemented 3/2020 and Date reviewed and revised 6/2023; indicated: Item 13-Discharge Against Medical Advise (AMA). a. The resident and family/legal representative should be informed of risks involved, the benefits of staying at the facility, and alternatives to both. Under no circumstances will the facility force, pressure or intimidate a resident into leaving AMA. b. The physician should be notified of the intended AMA discharge and encourage to speak with the resident to encourage them to stay at the facility. c. Documentation of this notification should be entered in the nurses' notes by the nursing department. The social services designee should document any discussions held with the resident/family in the service services progress notes if present. d. Notify Adult Protection Services, or other entity, as appropriate if self-neglect is suspected. Document accordingly.

Based on record reviews and interviews, the facility failed to implement their abuse and neglect policy as evidenced by staff failure to provide care and services including adequate supervision for one (Resident number 1) out of three residents sampled during the time of this survey. This deficient practice has the potential to affect all residents residing in the facility. This enabled resident number 1 to go missing from the facility undetected on [DATE]. The resident was not located until 8:30 AM on [DATE] deceased in a locked closet and his body was decomposed. Refer to F600, F689 and F835 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 ,d+[DATE], 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 Policies and Procedures titled Missing Resident with dated issued [DATE] indicates: It is the intent of the facility to be aware of its resident's, usual habits and location as reasonably practicable. This is with he intent of not invading privacy but to identify a possible missing resident. Procedure: 1. In the event that any staff member identifies that they cannot find a resident in a place that resident is anticipated to be, the staff member will alert their supervisor for assistance, once affirming that the resident was not signed out on leave. 2. The supervisor would assume control of the search. 3. The supervisor would alert staff of the identity of the resident and direct designated staff to participate in the search. 4. The supervisor in charge of the will not assume that resident has left facility and will: a. Re-affirm if the resident could be out of the facility on authorized leave the facility where reaffirming for resident could be out of the facility on an authorized or pass by reviewing the facility sign on process. b. Determine if it's prudent to call the resident's family or other visitors. If there is a possible concern that resident was taken out potentially they did not sign the resident out. c. If the resident is not authorized to leave facility independently. Initiate a search of the facility and premises by assigning staff to look in various areas. d. If the resident is not located is not located in a reasonable amount of time, the Administrator and Director of Nursing (DON), the resident's representative, the attending physician and law-enforcement official will be notified as indicated . e. If the resident remains unable to be located and or is not authorized to leave the facility independently; Initiate an extensive search of the surrounding areas. 5. When a missing person is not located within the confines of the facility building, then the supervisor in charge would direct designated staff to participate in an outside facility grounds search which may include but is not limited to the roof of the building, the parking lot and any outside parked vehicle, etc. 6. In the event that a staff member observes attempting a resident attempting to leave premises without supervision, and is concerned that the resident would not normally be a be appropriate to do so independently , the staff member will: a. call for assistance then calmly approach the resident (attempting to initiate a friendly chat as possible), and in a courteous manner attempt to redirect or guide the resident back to the facility; b. if the resident is upset or agitated and is not easily redirected or guided, the staff member will continue walking with the resident either next to or behind them to provide support, supervision and safety . Review of the Demographic Face Sheet for Resident number 1 documented the resident was initially admitted on [DATE] with diagnoses that included but not limited to cerebral infarction, difficulty in walking, cognitive communication deficit and altered mental status. Review of the Minimum Data Service (MDS) 5-Day assessment dated [DATE] for Resident number 1 documented the resident's Brief Interview of Mental Status (BIMS) Summary Score was 12, indicating moderate cognitive impairment and able to make his needs known, vision was impaired with no corrective lenses, wandering behavior was noted, required partial/moderate to substantial/maximal assistance for ADLs (activities daily living) and there was no wander/elopement alarms used. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for [DATE] documented the resident was receiving the following medications: Lorazepam tablet 0.5 mg (milligrams) give 1 tablet by mouth two times a day for anxiety; Seroquel oral tablet 100 mg give 1 tablet by mouth at bedtime for agitation related to altered mental status and a psych consult was written for a diagnosis of agitation on [DATE]. The resident did not have an order for a wander elopement alarm bracelet. Review of the Behaviors Monitoring Sheets for [DATE] documented the resident's behaviors were monitored on [DATE]-[DATE] at day, evening and night shift. On [DATE] day shift he had behaviors and was given food (code 7); On [DATE] night shift he had behaviors and was given food (code 7) and on [DATE] day shift he had behaviors and refer to progress note (code 9). Review of care plan's written [DATE] for Resident number 1 documented the resident had a discharge care plan and had wishes to return/be discharged to community/prior living arrangements and resident had a falls care plan and was at risk for falls related to unsteady gait, vision impairment. The resident did not have a wandering/elopement care plan. Review of the progress notes documented the following: Dated [DATE] time stamped 04:58 Behavior Note: Resident was washed and made comfortable in bed still taking off clothes redirected with food beverage peri care polite conversation. Resident still taken off clothing pass on to ,d+[DATE] shift to follow up; Dated [DATE] time stamped 05:37 Behavior Note: Resident walking in hallway going in other resident rooms and yelling redirected with food beverage peri care and polite conversation. Resident went to bed and resting comfortable, pass on to ,d+[DATE] shift to follow up; Dated [DATE] time stamped 21:16 Narrative Note (General): Overheard a resident yelling Don't hit me. Immediately responded and noted Resident#1 coming out of another resident's room. Resident assessed and complained of pain to left shoulder, back, and head. No open area and no bruising noted. Resident rated pain as a 3 on a ,d+[DATE] pain scale. PRN (as needed) pain medicine given. Resident confused and alert to person. Assisted resident back to his room. Call placed to MD (medical doctor). MD made aware and no new orders given. Call placed to resident's sister; Dated [DATE] time stamped 15:50 Narrative Note (General): Around 1 PM resident noted as agitated requesting to leave the facility. When asked why resident stated that he just did not want to be here anymore. Resident noted as self-responsible, made supervisor aware. Teaching provided regarding a facilitated transfer and supervisor called family but no answer. Resident refused and stated that he was leaving. Teaching provided regarding risks. Presented AMA (against medical advice) however resident refused to sign. Resident then left facility alert and oriented in no distress. Will make another attempt to inform family; Dated [DATE] time stamped 20:20 Narrative Note (General): Call placed to [ local community-based agency] for wellness check, spoke to [local community-based agency] who stated only local police do wellness checks however would document call. [Local police] was contacted for a wellness check and an address was provided and dated [DATE] time stamped 12:44 Narrative Note (General): Resident daughter and granddaughter arrived at the facility, no concerns voiced however stated that the resident does not like to stay in one place for a long period of time and is violent and agitated at times. Family thanked staff for contacting [local community-based agency] and [police for the wellness check]. Review of the Elopement Risk Assessment/Evaluation dated [DATE] documented: The resident upon his Admission was not at risk for elopement and a score of three. Review of the Against Medical Advice Form (AMA) for Resident number 1 dated [DATE] documented the resident did not sign the form and two signatures were documented below the resident's signature line. The signatures were the Staff A, Licensed Practical Nurse (LPN), Nurse Unit Manager 7:00 AM to 3:00 PM shift and Staff D, Registered Nurse (RN) 7:00 AM to 3:00 PM shift. The facility's Transfer and Discharge policy indicated in Item 13: Discharge Against Medical Advise (AMA). a. The resident and family/legal representative should be informed of risks involved, the benefits of staying at the facility, and alternatives to both. Under no circumstances will the facility force, pressure or intimidate a resident into leaving AMA. b. The physician should be notified of the intended AMA discharge and encourage to speak with the resident to encourage them to stay at the facility. c. Documentation of this notification should be entered in the nurses' notes by the nursing department. The social services designee should document any discussions held with the resident/family in the service services progress notes if present. d. Notify Adult Protection Services, or other entity, as appropriate if self-neglect is suspected. Document accordingly. On [DATE] at 10:46 AM, Staff A, Licensed Practical Nurse (LPN), Nurse Unit Manager 7:00 AM to 3:00 PM shift stated, The resident was sitting in a wheelchair on the day he left. He was restless, anxious. He was Creole speaking and a little English. We assessed him. He stated, He wanted to leave the facility. We educate the patient and told him the risks of him leaving. He was still restless, would stand up in the chair and we re-directed him. I went to the morning meeting, when I came back I saw the nurse, [Staff D], RN talking to the resident trying to redirect him. We spoke to him, and he didn't want to accept what we were trying to tell him. I looked in the [computer program] to see if the resident was self-responsible and I noted that he was, I let the DON (Director of Nursing) know. We presented to the resident the AMA (against medical advice) documentation, educated him on it and he refused to sign it, and he was anxious. I left him with the nurse. He had anxious behavior the day he left. He would go to different rooms and had exit seeking behaviors. I didn't see him walk out the building. When I came to his room, his belongings were still in his room. The nurse [Staff D], RN didn't tell everybody that the patient went AMA. The staff was asking about the resident. The procedure when a resident being discharged we present the resident is self-responsible to self, education is given by the nurse, who is in charge with the nurse. If they leave without medical advice, the medication will not go with them. I am not sure if the family was called when the resident was anxious. According to this resident, he wanted to go home. Vitals were stable. He was given food. He was in a wheelchair, but he could walk. The Administrator was notified by the nurse. I am not sure if the Administrator went to talk to the resident. The Certified Nursing Assistant (CNA) assigned to the resident was providing care to another resident. We let the doctor know, let the family know, we give them the paperwork. I think the nurse called the doctor. I don't know what the doctor say. He was anxious but not in an aggressive way. I was made aware; he went AMA after lunch around 1:00 PM. She didn't tell me [Staff D], RN right away the resident went AMA. He would eat lunch in his room or in the hallway. On [DATE] at 11:26 AM, Staff B, Certified Nursing Assistant (CNA) 7:00 AM to 3:00 PM shift stated, I was assigned to him. I made rounds, he was alert and talkative. He spoke a little bit of English but spoke mostly Creole. At first he was in bed, afterwards he was cleaned and transferred to the wheelchair. He was in the hallway close to the nurses' station. In the morning when I did rounds, he was telling me he wanted to leave. I asked him why he said he wanted to go home. I expressed to my supervisor, [Staff A], LPN. They went to talk to him [ Staff A, LPN] and Staff D, RN. I was moving about going to see about my other residents. My second time working with him on that day. He was very anxious, he would go from bed to bed, walking and opening doors, stand by the exit doors. The nurse knew he was going from room to room. He would stand by the exit door right outside of his room. I only work here three days a week. He was combative and would argue with you. I would say to him come back to your room, if I saw him going to another room. We would let our supervisor know if we see the resident wandering. I wasn't informed that he went AMA. When I left on my shift at 3:00 PM, he was in his wheelchair on the floor. I came back to work on the following Tuesday, I was made aware he was missing. On [DATE] at 1:19 PM with the Administrator/Risk Manager stated, Somebody had alerted me that there was a missing resident on [DATE] after 1:00 PM. We started looking for the resident in the building and out of the building. Some of us went driving around. Code green was called and that means someone is missing. A few minutes after we had gone driving around, [Staff A], LPN the Supervisor called me and told me that he wasn't missing but he left AMA. He was dealing with the nurse and the resident when he said he wanted to leave, and he refused to sign the AMA form. When he told me that I said it wasn't an elopement and we went back to the building. The weather was bad, and I asked [Staff A], LPN did he say where he was going. Nobody escorted him out of the building, and we didn't know which way he went. Since it was bad weather, we called [local agency] to do a wellness check, and the family house was nearby. [local community-based agency] told us they don't do wellness checks anymore and to call local law enforcement and we did. Law enforcement went to the address (the resident's niece), and he wasn't there. When the police went to the house they decided to file a missing person report. We wanted to keep looking for him so some of us, kept looking for him. We were driving around the area looking for him. The next day on the 23 rd the daughter and the granddaughter came to the building to meet with me, the DON (director of nursing) and the ADON (Assistant Director of Nursing). The daughter said he likes to walk the street and live on the street. His usual spot is by [local hospital]. We called the police that we had spoken to and gave them the information so they could look as well. On [DATE] the following Monday, the sister and the niece came to the building, asking questions regarding the situation to me and [DON]. The niece said he had dementia. We checked the chart and there was no documentation in our chart or the hospital chart that he had dementia. She said she was going to talk to the hospital because that was neglectful to not use that as a diagnosis. We did a neglect report on [DATE] and we unsubstantiated it. He was alert and oriented times three on our chart and the hospital's chart. I completed the 5-day report on yesterday. On [DATE], I get a call from [the DON] around 8:30 AM that they found a body in the closet. Somebody was saying that there was a bad odor. The maintenance assistant started looking in the vents and rooms and couldn't find the smell. He had housekeeping come and open the door for him and he found the body was decomposed. [DON] called me, and I came straight over. The cops were here, the area was closed off and we couldn't go back there. At that point, the detective was asking questions and interviewing the staff. The medical examiner took the body and when the detective was done we started cleaning the area Sometimes they notify me if a resident leaves AMA. On [DATE] at 1:49 PM, the Director of Nursing (DON) stated, On that day, somebody told me in the afternoon that a resident was missing. I went out and looked for the resident. I looked around and I came back. I was informed the resident went out AMA. Late that afternoon, it was about to rain, I asked the Administrator and the ADON, do you think we need to do a wellness check. ADON called the [local community-based agency], and they said they don't do a wellness check anymore and to call the police. We called the police, explained to the police what happened. I went back out and drove around to look for him. I went all the way to the [local hospital] and I didn't see him. I couldn't find the resident. The police asked should we file a missing person's report, and I said no because he filed an AMA. [Staff A], LPN the Supervisor and [Staff D], RN the nurse for the resident signed on the AMA form. We had procedures in place for elopement and AMA which is a part of the education plan. I don't know if he had a psych consult. Subsequent interview with the DON on [DATE] at 3:18 PM. He stated, The resident never received a psych consult. He was gone by the time the psychiatrist came to see him. On [DATE] at 2:08 PM with the Maintenance Assistant via Spanish translator he revealed the nurses called him because of the bad smell. He checked the attic in J wing, the AC duct. He went to the dining room because the smell was strong. The door was locked, housekeeping opened the door. When he opened the door he found the body. Only saw the legs and he left quickly. He called another staff member and he came and looked. On [DATE] at 7:24 AM Staff E, Registered Nurse (RN) 11:00 PM to 7:00 AM shift stated, He had the behaviors of wandering. He would go into other patients room and the patients would get mad. He was very mean and angry. I gave him a choice to go to his room. Sometimes he would go and if not I would have him take a chair and sit down. He spoke a little bit of English. On [DATE] at 9:35 AM via telephone Staff D, Registered Nurse (RN) 7:00 AM to 3:00 PM shift stated, He was my patient, and I was in the hallways. At 11:22 AM, I gave him his medication. I moved on to my next patient. The CNA around 1:00 PM or 2:00 PM and she said to me he wanted to leave. I went to talk to the supervisor [Staff A], LPN. I tell him the CNA report to me that the patient wanted to leave. He said we have to talk to the patient. He cannot leave. He would have to sign a paper, AMA form. He refused to sign the form. If he want to leave, he had to sign the paper. When he refused to sign the paper, [Staff A], LPN said that two people have to sign the form before the patient can leave. [Staff A], LPN signed the paper first and I signed the paper next. I left and took care of my other patients. I didn't see the resident after that. The procedure for AMA give them the paper to sign and they can go. I did not call the doctor. Once I left the supervisor [Staff A], LPN he said he would take care of it. He was alert and oriented times three. That morning, he did not have any wandering behavior. Sometimes I would see him wandering into other patients room. I would talk to him in Creole don't go in the room he would come back around. He would walk around and go everywhere. I would have to say yes [Staff A], LPN told the social services. I don't know if she came to see him.

Based on observations, interviews, record review, the facility failed to ensure the facility's environment was safe and residents were adequately supervised, as evidenced by one (Resident #1) out of three vulnerable resident sampled with exit seeking behaviors voice his intent to leave the facility refused to sign an Against Medical Advice (AMA). was not adequately supervised and monitored by the facility's staff who did not see the resident exit the facility The facility had an unsecured closet that was being used for storage that Resident #1 entered undetected. Resident #1 decomposed body was found for 12 days after staff reported the resident left the facility AMA. Refer to F600, F607 and F835 The findings include: Observation on 09/04/24 at 9:36 AM with the [NAME] President of Operations and the Regional Director of Operations of the space within which Resident #1 was found revealed the space was located in the rear dining room that is used for activities located in the J Unit, cameras were observed the dining area which the facility's administrative staff said were nonfunctional cameras. The door to the closet where Resident # 1 was found had a Key Entry Lever Handle Lock; there were several boxes and a working toilet that had boxes stacked on it. The Regional Director of Operations revealed the room was previously used as a shower room and is now storage closet. A tour of the area outside the dining/activities area revealed the two emergency exit doors had alarms that required a code prior to opening surveillance cameras were also noted on the building's exterior. When asked if the cameras were working The [NAME] President of Operations revealed the cameras were not working and were left in place by the previous owner. Review of Resident # 1's admission Records revealed an admitted [DATE]. The contacts information documentation indicated the resident as Self, the emergency contact #1 listed daughter #2 Granddaughter and contact information listed for two sisters. Review of the clinical records revealed diagnoses that included but not limited to: Altered Mental Status, Cognitive Communication Deficit, Cerebral Infarction, Difficulty in Walking and Diabetes Mellitus. Review of Resident #1's August 2024 Physician's Order Sheets and Medication Administration Records revealed the resident was receiving medications that included but not limited to Lorazepam Tablet 0.5 mg 1 tablet by mouth two times a day for anxiety; Seroquel Oral Tablet 100 mg 1 tablet by mouth at bedtime for Agitation related to altered mental status. There was an order for -Psych consult for diagnosis of agitation with revision dated 8/18/2024 that according to the Director of Nursing the resident did not receive because he was no longer in the facility. Review of Resident #1 admission care plans dated 8/15/24 revealed The resident resident had a falls care plan and was at risk for falls related to unsteady gait, had vision impairment and no care plan for wandering/elopement vision impairment. Care Plans initiated 08/20/2024 Revision on: 08/28/2024 revealed Resident #1 is at risk for falls related to Unsteady gait and Vision impairment. Goal: Resident will be free of fall related injuries by next review date. Interventions: .Check at frequent intervals to monitor for unsafe actions and intervene promptly. Focus ;risk for further alteration; in neurological functioning related to history of Cardiovascular Attack (Stroke) and Cerebrovascular Disease.; Date Initiated: 08/21/2024. Revision on: 08/28/2024. Risk for complications of abnormal blood sugar related to diagnosis of Diabetes Mellitus date initiated: 08/21/2024, Revision on: 08/28/2024. Review of Resident #1's 5- Day Minimum Data Set (MDS) dated [DATE] indicated the resident vision is impaired, was moderately impaired cognitively and had wandering behaviors that occurred 1 to 3 days. and there was no wander/elopement alarms used. Review of Resident # 1's ELOPEMENT RISK ASSESSMENT/EVALUATION dated 8/21/24 completed and documented by the DON revealed an at-risk score of 11.0 meaning the resident was a high risk for elopement Resident #1 was being monitored for behaviors since his admission on 08/14 /24 until; the behavior monitoring sheets documentation revealed on 8/17/24 during the day shift he had behaviors and was given food, on 8/20/24 he had behaviors during the night shift and was given food, he had behaviors during the day shift (date of the incident) which documented refer to progress note. Review of the progress notes written by Registered Nurse (RN); Staff D dated 08/22/24 time stamped 15:50 documented: Around 1:00 PM resident noted as agitated requesting to leave the facility. When asked why, resident stated that he just did not want to be here anymore. Resident noted as self-responsible, made supervisor aware. Teaching provided regarding a facilitated transfer and supervisor called family but no answer. Resident refused and stated that he was leaving. Teaching provided regarding risks. Presented AMA however resident refused to sign. Resident then left facility alert and oriented in no distress. Will make another attempt to inform family. Review of the Discharge Without Physician's Approval Form Dated 8/22/24 revealed the resident had not signed above the line that indicated Signature of Resident the above the date line was dated 8-22-24. A signature belonging to the Licensed Practical Nurse Unit Manager (Staff A) was noted below the blank resident signature line. Review of Narrative Note written by the Assistant Director of Nursing (ADON) revealed; (General) dated 8/22/2024 timestamped 20:20: Call placed to [local community-based agency] for wellness check, spoke to [local community based agency staff] who stated only local police do wellness checks however would document call. [Local police department] was contacted for a wellness check and an address was provided. Review of Narrative note written by the ADON dated 8/23/2024 time stamped 12:44 documented: Resident daughter and granddaughter arrived at the facility, no concerns voiced however stated that the resident does not like to stay in one place for a long period of time and is violent and agitated at times. Family thanked staff for contacting [local community-based agency] and [local law enforcement] for the wellness check. Review of the facility's ABUSE LOG: Dated August 2024 revealed, Resident #1 was listed on the abuse log for neglect on 8/22/24 and was unsubstantiated; Date 8/26/24; [Local community-based agency] called-8/22/24; Accepted/Rejected-Rejected; Allegations-Neglect; 5-Day Federal-9/02/24; Comments-Unsubstantiated. The facility's ELOPEMENT INCIDENT LOG for August 2024 had no incidents of elopements. During an interview on 9/04/24 at 10:46 AM the 7:00 AM to 3:00 PM Licensed Practical Nurse (LPN) Nurse Manager revealed; Resident #1 was sitting in a wheelchair on the day he left. The resident was anxious was restless and anxious. He was Creole speaking and spoke a little English. He was assessed and he wanted to leave the facility. We educate the patient and tell him the risks of him leaving. He was still restless, would stand up in the chair and re-directed him. I went to the morning meeting, when I came back I saw the nurse, [Staff D, RN] talking to the resident trying to redirect him. We spoke to him, and he didn't want to accept what we were trying to tell him. I looked in the [computer program] to see if the resident was self-responsible and I noted that he was, I let the DON know. We presented to the resident the AMA documentation, educated him on it and he refused to sign it, and he was anxious. I left him with the nurse. He had anxious behavior the day he left. He would go to different rooms and had exit seeking behaviors. The Nurse Manager was asked if he saw Resident #1 leaving the facility and if anyone escorted the resident from the facility. He stated: I didn't see him walk out the building. When I came to his room, his belongings were still in his room. The nurse [Staff D] didn't tell everybody that the patient went AMA. The staff was asking about the resident. The LPN Nurse Manager explained the facility's policy and procedure when a resident is being discharged , he explained when a resident is being discharged and the resident is self-responsible, education is given by the nurse, who is in charge with the nurse. If they leave without medical advice, the medication will not go with them. I am not sure if the family was called when the resident was anxious. According to this resident, he wanted to go home. Vitals were stable. He was given food. He was in a wheelchair, but he could walk. The Administrator was notified by the nurse. I am not sure if the Administrator went to talk to the resident. The Certified Nursing Assistant (CNAs) assigned to the resident was providing care to another resident. We let the doctor know, let the family know, we give them the paperwork. I think the nurse called the doctor. I don't know what the doctor say. He was anxious but not in an aggressive way. I was made aware he went AMA after lunch around 1:00 PM. She didn't tell me [Staff D] right away that the resident went AMA. The Nurse Manager was asked if Resident #1 ate lunch that day and where did the resident usually eat his lunch. The Nurse manager stated, He would eat lunch in his room or in the hallway. The nurse manager was asked how he came to the conclusion that Resident # 1 was AMA if no one saw the resident exit the facility and may just be missing. and may have possibly be missing because his belongings were still in his room. He revealed he did not see the resident leave the facility. During an interview on 09/04/24 at 11:26 AM the Resident # 1's assigned Certified Nursing Assistant (CNA), Staff B on the day of the incident reported he spoke a little bit of English but mostly spoke Creole. On the day of the incident at first he was in bed, afterwards he was cleaned and transferred to the wheelchair. He was in the hallway close to the nurses' station. In the morning during her rounds, he told her he wanted leave wanted to go home. Staff B stated: I expressed to my supervisor, [Staff A]. They went to talk to him (Staff A and Staff D]. I was moving about going to see about my other residents. This was my second time working with him on that day. He was very anxious, he would go from to bed, walking opening doors, by the exit doors. The nurse knew he was going from room to room. He would stand by the exit door right outside of his room. I only work here three days a week. He was combative and would argue with you. I would say to him come back to your room, if I saw him going to another room. Once we let our supervisor know if we see the resident wandering. I wasn't informed that he went AMA. When I left on my shift at 3:00 PM, he was in his wheelchair on the floor. I came back to work on the following Tuesday, I was made aware he was missing. During an interview on 9/04/24 at 1:19 PM the Nursing Home Administrator (NHA) reported after 1:00 PM on 8/22/2024 she was alerted that a resident was missing. We started looking for the resident in the building and out of the building. Some of us went driving around. Code green was called and that means someone is missing. A few minutes after we had gone driving around, [Staff A] called me and told me that he wasn't missing but he left AMA. He was dealing with the nurse and the resident when he said he wanted to leave, and he refused to sign the AMA form. When he told me it wasn't an elopement, and we went back to the building. The weather was bad, and I asked [Staff A] did he say where he was going. The NHA was asked if anyone escorted the resident out of the building. She stated: Nobody escorted him out of the building, and we didn't know which way he went. Since it was bad weather, we called (local community-based agency] to do a wellness check and the family house was nearby. [Local community-based agency] told us they don't do wellness checks anymore and to call local law enforcement and we did. Law enforcement went to the address (niece), and he wasn't there. When the police went to the house they decided to file a missing person report. (Since the facility became aware a missing person report had been filed with the police by the family after the wellness check was completed and the resident was not located. The NHA reported staff checked both inside and outside of the facility and when asked how they were able to confirm all area were checked within the facility she did not provide an answer. The NHA was asked why they did not continue searching in the facility every day and open all doors in the facility, no answer was provided the NHA stated all hospitals were checked and areas close to the facility the NHA was asked if they called the police to get any updates. The NHA was asked if they are positive all areas were checked and if anyone had considered looking in that closet and asking for a key to open it she stated she never thought of that. The NHA was asked if no one heard sounds from the closet or smelled anything while activities were being done in that area she said no. the NHA acknowledged she was unable to confirm if a thorough search was completed within the facility on 08/22/2024). We wanted to keep looking for him so some of use kept looking him. Driving around the area. The next day on the 23 rd the daughter and the granddaughter came to the building to meet with me, [ DON and ADON]. The daughter said he likes to walk the street and live on the street. His usual spot is by [local hospital]. We called the police that we had spoken to and gave them the information so they could look as well . On 8/26/24 the following Monday, the sister and the niece came to the building, asking questions regarding the situation me and (DON). The niece said he had dementia; we checked the chart and there was no documentation in our chart or the hospital chart that he had dementia. She said she was going to talk to the hospital because that was neglectful to not use that as a diagnosis. We did a neglect report on 8/26/24 and we unsubstantiated it. He was alert and oriented times three on our chart and the hospital's chart. I completed the 5-day report on yesterday. On 9/02/24, I got a call from [DON] around 8:30 AM that they found a body in the closet. Somebody was saying that there was a bad odor. The maintenance assistant started looking in the vents and rooms and couldn't find the smell. He had housekeeping come and open the door for him and he found the body was decomposed. [DON] called me, and I came straight over. The cops were here, the area was closed off and we couldn't go back there. At that point, the detective was asking questions and interviewing the staff. The medical examiner took the body and when the detective was done we started cleaning the area. The NHA was asked if she should have been notified that the resident was agitated and wants to leave AMA and also be notified of all AMAs, she stated: Sometimes they notify me if a resident leaves AMA. They are supposed to educate the resident about what AMA means. The NHA was as asked if it was unusual for a resident to leave without taking their belongings. She stated: I went in his room and his things were there. We have had some AMAs, and they have left their things because they had too many things. The NHA was asked if she was sure everywhere in the facility was checked including that specific closet. She stated: The DON said he checked that closet, but it was locked. It was an old shower room, and we had been using it as a storage room for boxes and papers. I wasn't aware that it could lock from the inside. When asked why they did not get the keys so the door could be unlocked and checked she did not respond. On 9/04/24 at 1:49 PM, the Director of Nursing (DON) revealed on the afternoon of the incident someone told him that a resident was missing, he went to look for the resident in the area. When he returned to the facility he was told the resident went out AMA. Late that afternoon, it was about to rain, he asked the Administrator and the ADON, if a wellness check needed to be done. The ADON called [local community-based agency], and they told her they do not do a wellness checks anymore and to call the police. The police was called, and they told the police what happened. The DON reported he went back out to search for the resident and did not find the resident. The police asked should we file a missing person's report, and I said no because he filed an AMA. [Staff A], LPN the Supervisor and [Staff D], RN the nurse for the resident signed on the AMA form. We had procedures in place for elopement and AMA. The DON was asked if he was positive all areas in the facility was checked. He reported everywhere was checked. The DON reported he did not know the resident was agitated and wanted to leave. During an interview via telephone on 09/05/2024 at 1:16 PM, the Medical Director was asked if he was notified of Resident #1 wanting to leave the facility AMA. He stated, I was not notified. I became aware of the incident while I was in the facility on Thursday (08/22/2024) that afternoon around 2:00 PM to 3:00 PM and was told they were looking for a missing resident. He reported, if a resident wishes to leave AMA and is alert the resident will need to sign the AMA form, if the resident is unable to sign and they have a proxy the proxy will need to sign, if the proxy cannot be located to sign a guardian will be appointed to sign. When a Resident is agitated even if they are responsible for themselves, the staff cannot let that resident leave AMA. An agitated resident should be sent to the hospital; and the family or emergency contacts should be notified. Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and Procedure revision date was on 10/2022, 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 Transfer and Discharge (including AMA. Item 13-Discharge Against Medical Advise (AMA) Date Implemented 3/2020 and Date reviewed and revised 6/2023; indicated: a. The resident and family/legal representative should be informed of risks involved, the benefits of staying at the facility, and alternatives to both. Under no circumstances will the facility force, pressure or intimidate a resident into leaving AMA. b. The physician should be notified of the intended AMA discharge and encourage to speak with the resident to encourage them to stay at the facility. c. Documentation of this notification should be entered in the nurses' notes by the nursing department. The social services designee should document any discussions held with the resident/family in the service services progress notes if present. d. Notify Adult Protection Services, or other entity, as appropriate if self-neglect is suspected. Document accordingly.

Based on record reviews and interviews the facility's administrative staff failed to ensure staff implemented a safe AMA discharge process by failing to monitor/escort a resident leaving the facility; failed to communicate and ensure efficient preventative measures to prevent the neglect of one resident (Resident number 1) out of three sampled residents who displayed exit seeking behaviors. As evidenced by failure by staff to implement assigned level of supervision for resident number 1 who was at risk for elopement, had exit seeking behaviors, wandered the unit and near exit doors and voiced his intent to leave the facility. These deficient practices enabled Resident number 1 to go missing from the facility undetected on [DATE]. The resident was not located until 8:30 AM on [DATE] deceased and decomposing in a locked closet. Refer to F600, F607 and F689 The findings included: 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 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 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 responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Director of Social Services documented: The primary purpose is to plan, organize, develop and direct the overall operation of the facility social services department in accordance with current federal, state and local standard guidelines and regulations and to assure that the facility is maintained in a clean, safe and comfortable manner. Record review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and Procedure revision date was on ,d+[DATE], 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, Residents at Risk for Elopement Policy and Procedure issued [DATE] documented: Policy Guidelines: The facility strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk for elopement, implement risk reduction strategies for those identified as an elopement risk, institute measures for resident identification at the time of admission and conduct a coordinated resident search in the event of a missing resident. II Definitions: Wandering refers to a cognitively impaired resident's ability to move about inside the facility aimlessly, but often with purpose and without an appreciation of personal safety needs and who may enter a dangerous situation. III Procedural Components: A. Assessment: 2) An elopement risk evaluation is completed on all residents on admission and with a change in condition or mental status; 4) g. iv. Exit-seeking (the resident is intent on leaving the unit or facility, looking for exits and hovering at exits waiting for the opportunity to leave with someone or pushing on a door); B. Risk Reduction Measures: 1) Interventions that may be used for residents identified as high risk for elopement include: b) Room placement close to common areas such as the nurses' station and away from exits and f) Transfer to a more suitable or more secured unit. Review of the facility's policy titled, Missing Resident Policy and Procedure issued [DATE] documented: Policy: It is the intent of the facility to be aware of its resident's usual habits and locations as reasonably practicable. Procedure: 1) In the event that any staff member identifies that they cannot find a resident in a place that the resident is anticipated to be, the staff member will alert their supervisor for assistance once affirming that the resident was not signed out on leave; 2) The supervisor would assume control of the search; 3) The supervisor would alert staff of the identity of the resident and direct designated staff to participate in the search; 4) The supervisor in charge of the search will not assume that the resident has left the facility and will: b) Determine if it is prudent to call the Residents family or other visitors if there is a possible concern that the resident was taken out and potentially they did not sign the resident out; c) If the resident is not authorized to leave the facility independently, initiate a search of the facility and premises by assigning staff to look in various areas; d) If the resident is not located in a reasonable amount of time, the Administrator and the Director of Nursing (DON), the resident's representative, the Attending Physician and law enforcement officials will be notified as indicated and e) If the resident remains unable to be located and or is not authorized to leave the facility independently, initiate an extensive search of the surrounding area. Review of the Demographic Face Sheet for Resident #1documented the resident was initially admitted on [DATE] with diagnoses that included but not limited to cerebral infarction, difficulty in walking, cognitive communication deficit and altered mental status. Review of the Minimum Data Service (MDS) 5-Day assessment dated [DATE] for Resident #1 documented the resident's Brief Interview of Mental Status (BIMS) Summary Score was 12, indicating moderate cognitive impairment and able to make his needs known Review of care plan's written [DATE] for Resident #1 documented the resident had a discharge care plan and had wishes to return/be discharged to community/prior living arrangements and resident had a falls care plan and was at risk for falls related to unsteady gait, vision impairment. The resident did not have a wandering/elopement care plan. Review of the Elopement Risk Assessment/Evaluation dated [DATE] documented: The resident upon his Admission was not at risk for elopement and a score of three. Review of Resident # 1's Elopement Risk Assessment/Evaluation dated [DATE] completed and documented by the DON revealed an at-risk score of 11.0 meaning the resident was a high risk for elopement Review of the Against Medical Advice Form (AMA) for Resident #1 dated [DATE] documented the resident did not sign the form and two signatures were documented below the resident's signature line. The signatures were the Staff A, Licensed Practical Nurse (LPN), Nurse Unit Manager 7:00 AM to 3:00 PM shift and Staff D, Registered Nurse (RN) 7:00 AM to 3:00 PM shift. On [DATE] at 1:19 PM during an interview the Administrator/Risk Manager stated, Somebody had alerted me that there was a missing resident on [DATE] after 1:00 PM. We started looking for the resident in the building and out of the building. Some of us went driving around. Code green was called and that means someone is missing. A few minutes after we had gone driving around, [Staff A], LPN the Supervisor called me and told me that he wasn't missing but he left AMA. He was dealing with the nurse and the resident when he said he wanted to leave, and he refused to sign the AMA form. When he told me that I said it wasn't an elopement and we went back to the building. The weather was bad, and I asked [Staff A], LPN did he say where he was going. Nobody escorted him out of the building, and we didn't know which way he went. Since it was bad weather, we called [local agency] to do a wellness check, and the family house was nearby. [local community-based agency] told us they don't do wellness checks anymore and to call local law enforcement and we did. Law enforcement went to the address (the resident's niece), and he wasn't there. When the police went to the house they decided to file a missing person report. We wanted to keep looking for him so some of us, kept looking for him. We were driving around the area looking for him. The next day on the 23rd the daughter and the granddaughter came to the building to meet with me, the DON (director of nursing) and the ADON (Assistant Director of Nursing). The daughter said he likes to walk the street and live on the street. His usual spot is by [local hospital]. We called the police that we had spoken to and gave them the information so they could look as well. On [DATE] the following Monday, the sister and the niece came to the building, asking questions regarding the situation to me and [DON]. The niece said he had dementia. We checked the chart and there was no documentation in our chart or the hospital chart that he had dementia. She said she was going to talk to the hospital because that was neglectful to not use that as a diagnosis. We did a neglect report on [DATE] and we unsubstantiated it. He was alert and oriented times three on our chart and the hospital's chart. I completed the 5-day report on yesterday. On [DATE], I get a call from [the DON] around 8:30 AM that they found a body in the closet . [DON] called me, and I came straight over. The cops were here, the area was closed off and we couldn't go back there. At that point, the detective was asking questions and interviewing the staff. The NHA was asked about the protocol when a resident is leaving AMA and if she is notified; the NHA stated: Sometimes they notify me if a resident leaves AMA.

Based on observation record review and interviews the facility failed to ensure residents' medical records are accurate in accordance with accepted professional standards and practices for two (Resident #1 and Resident #3) out of three residents sampled, as evidenced by an Elopement Risk Assessment information for Resident#1 was struck out by the Director of Nursing (DON) when written by the Assistant Director of Nursing (ADON); and a progress note for Resident #1 that indicated Resident #1 left Against Medical Advice (AMA) without staff observation of Resident #1 exiting the facility and an Elopement Care Plan for Resident #3 noted with interventions that included a monthly [wander management system] check inconsistent with an attestation from the facility stating [wander management systems] are not used, These practices has the potential to affect any of the residents residing in the facility. 1) Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with diagnoses that included but not limited to cerebral infarction, difficulty in walking, cognitive communication deficit and altered mental status. Review of the Minimum Data Service (MDS) 5-Day assessment dated [DATE] for Resident number 1 documented the resident's Brief Interview of Mental Status (BIMS) Summary Score was 12, indicating moderate cognitive impairment and able to make his needs known, vision was impaired with no corrective lenses, wandering behavior was noted, required partial/moderate to substantial/maximal assistance for ADLs (activities daily living) and there was no wander/elopement alarms used. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for August 2024 documented the resident was receiving the following medications: Lorazepam 1 tablet by mouth two times a day for anxiety; Seroquel oral tablet at bedtime for agitation related to altered mental status and a psych consult was written for a diagnosis of agitation on 8/18/2024. Review of the Behaviors Monitoring Sheets for August 2024 documented the resident's behaviors were monitored on 8/14/24-8/22/24 at day, evening and night shift. On 8/17/24 day shift he had behaviors and was given food (code 7); On 8/20/24 night shift he had behaviors and was given food (code 7) and on 8/22/24 day shift he had behaviors and refer to progress note (code 9). Review of care plan's written 8/15/24 for Resident number 1 documented the resident had a discharge care plan and had wishes to return/be discharged to community/prior living arrangements and resident had a falls care plan and was at risk for falls related to unsteady gait, vision impairment. The resident did not have a wandering/elopement care plan. Review of the Elopement Risk Assessment/Evaluation for Resident number 1 dated 8/21/24 documented the resident was at risk with a score of 11.0. He was described as independently ambulatory, very confused, comatose, combative, depressed, or psychotic and impulsive behavior. The evaluation was documented by the Assistant Director of Nursing. On 8/22/24 time stamped 16:07 by the Director of Nursing (DON) documented the Elopement Risk Assessment/Evaluation was incomplete and the documentation was incorrect. On 9/04/24 at 1:49 PM during an interview the Director of Nursing (DON) stated, [Assistant Director of Nursing] (ADON) made a statement, and the elopement evaluation was struck out. On 9/04/24 at 2:49 PM the ADON stated, I did the elopement risk evaluation on 8/21/24. It was done on the wrong person. It was supposed to be for [another resident]. On 8/21/24, I placed the elopement risk in the wrong chart as I was working in two charts at once. As I was going to conduct an interview with [Resident#1], I noted another resident with exit seeking behavior in which I redirected then documented. I then went to talk to the staff to closely monitor him. I then went to clinical meeting and accidentally placed the elopement risk in [Resident #1's] chart as it was still open. The elopement risk was then struck out. [Resident #1's] Elopement Risk was done on 8/15/24 upon his admission and he was not at risk for elopement. He had a score of three. Review of the statement written concerning Elopement Risk Assessment/Evaluation documented: On 8/21/24, I placed the elopement risk in the wrong chart as I was working in two charts at once. As I was going to conduct an interview with [Resident #1], I noted another resident with exit seeking behavior in which I redirected then documented. I then went to talk to the staff to closely monitor him. I then went to clinical meeting and accidentally placed the elopement risk in [Resident #1's] chart as it was still open. The elopement risk was then struck out. Review of the Elopement Risk Assessment/Evaluation dated 8/15/24 documented: The resident upon his admission was not at risk for elopement and a score of three. 39177 Review of the progress notes written by Registered Nurse (RN); Staff D dated 08/22/24 time stamped 15:50 documented:: Around 1:00 PM resident noted as agitated requesting to leave the facility. When asked why, resident stated that he just did not want to be here anymore. Resident noted as self-responsible, made supervisor aware. Teaching provided regarding a facilitated transfer and supervisor called family but no answer. Resident refused and stated that he was leaving. Teaching provided regarding risks. Presented AMA however resident refused to sign. Resident then left facility alert and oriented in no distress. Will make another attempt to inform family. On 09/04/24 at 11:49 AM surveyor on the team attempted to contact Staff D and a voice message left with call back number. Record review of Policy and Procedure: Documentation in Medical record Date implemented: 4/2020 Date Reviewed/Revised: 10/2023 Policy: Each resident ' s medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident ' s progress through complete, accurate, and timely documentation. Policy Explanation and Guidelines: 6. Corrections to a medical record shall be made to clarify inaccurate information. a. Only the individual who made the original entry shall correct the entry. 48906 2) On 9/4/24 at 10:10 AM Resident #3 was observed seated on the bed eating lunch. An identification bracelet with the resident's name was observed on the wheelchair next to Resident #3. Resident #3 stated, I placed the name bracelet on my wheelchair to keep it safe. Record review of a list provided by facility of all residents at risk for Elopement revealed Resident #3 was at risk for Elopement. Record review of demographic sheet for Resident #3 revealed an admitted [DATE] and readmitted [DATE] with diagnosis that included Schizophrenia. Record review of the Quarterly Minimum Data Set (MDS) with reference date 6/20/24, Section C (Cognitive status) revealed a Brief Interview for Mental Status score of 12 out of 15 indicating moderate cognitive impairment. Section E (Behaviors) revealed Resident #3 had not exhibited wandering behaviors and Section P (restraints) revealed none were used. Record review of Care Plan initiated on 04/30/24 and revised on 6/1/24 revealed Resident #3 had behaviors of wandering with no purpose and a goal of Resident #3 will not have complications related to wandering behaviors thru next review with interventions that included: Maintenance to do monthly [wander management system] system check. Record review of the physician's order sheet revealed an order dated 6/6/24 for Risperidone oral tablet one milligram direction give one tablet by mouth two times a day for Schizophrenia, monitor behavior, mood, sleep, and appetite and an order dated 6/7/24 for Behavior Code 1: Agitated directions document # of times behavior occurred each shift every shift. Record review of Electronic Health record revealed an assessment of Elopement Risk dated 4/30/24 with a total score of 11, indicating a risk for Elopement. On 9/4/24 at 2:10 PM Staff G, Licensed Practical Nurse (LPN) stated: I am the nurse for [Resident #3] today. I am not aware if [Resident #3] is at risk for elopement, but we have an Elopement Book that is kept at the nursing station. the nurse showed surveyor the Elopement Book, Resident #3 was listed, and a picture provided. Staff G further stated: We have interventions in place to monitor residents who are at risk for elopement and [Resident #3] does not have a [wander management system]. On 9/4/24 at 3:10 PM; when asked about the wander systems check; the Maintenance Director stated, We do not do [wander management system] checks. Record review of Attestation from Facility revealed the facility does not use a [wander management system].

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 and was cited for Free of Accident Hazards, Supervision, Devices and Quality Assurance and Assessment (QA&A).during survey with Event ID # 4HN11, exit date [DATE] with noncompliance cited at a scope and severity (S/S) of No actual harm with potential for more than minimal harm that is not immediate jeopardy (D). Additional during survey Event ID # 8CDC11, exit date [DATE] QA&A with noncompliance cited at a S/S of D. During survey Event ID # 4E6811, exit date [DATE] Administration was cited at S/S of Actual harm that is not immediate jeopardy (G). On [DATE], the facility was negligent and failed to provide adequate supervision and effective services to prevent harm resulting in the death of one (Resident #1) out of three sampled residents with exit seeking behaviors, resulting in Resident #1 being found deceased in a locked room in the rear of the building after twelve days of being unaccounted for. These repeated deficient practices has the potential to affect any of the residents residing in the facility. Refer to F607, F689 and F835 The findings included: Record review of the facility's Quality Assurance Performance Improvement (QAPI) Program Policy and Procedure (revised [DATE]) documented the following: Policy-It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 3. The QAPI plan will address the following elements: f. Process to ensure care and services delivered meet accepted standards of quality. 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, Human Resources Manager, Rehab Director, Business Office Manager, Infection Control and Prevention Officer, Housekeeping Director, Social Services Director, Dietitian, MDS (Minimum Data Set) Coordinator, Medical Director, Activities Director, Food Service Director, and Regional Clinical Director, Director of Nursing (DON), and Assistant Director of Nursing (ADON). On [DATE] at 2:50 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 and sometimes the pharmacy and a CNA. The purpose of QAA is to review systems that are in place and review the reports of each department head to see where we can improve. We prioritize our Plans of Improvement by what mostly affect residents 'safety. We report to our corporate officers. We are currently working on Elopements, AMA and QAPI. We have a system for tracking adverse incidents by keeping a log and go over it the morning meetings and we do root causes analysis and the five whys to determine the causes of the event. Staff communicate concerns to the QAA committee by coming directly to myself or attending a monthly town hall meeting that includes an open forum. We have done audits on previous AMAs for last 90 days to make sure all steps were followed and if an error is found we know to educate. .

Based on observations, interview and record review, the facility's quality assurance and assessment committee (QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem areas related to repeated deficient practices; as evidenced by, review of the facility's history revealed during the survey with exit dated 03/24/2023 the facility was cited for these repeated deficiencies identified during this survey with exit dated 08/01/24 related to: F584 Safe/ Clean/ Comfortable/ Homelike Environment, F641 Accuracy of Assessments, F645 PASRR Screening for Mental Disorder/ Intellectual Disability, F656 Develop/implement comprehensive care plan, F684 Quality of Care, F791 Routine/Emergency Dental Services, F761 Label/Store Drugs & Biologicals and F867 QAPI/QAA Improvement Activities. This pattern of repeated deficient practice has the potential to affect any of the 208 residents residing in the facility at the time of the survey. The findings included: Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 5/29/24,6/12/24, and 7/9/24 documented the facility had a QAA Committee meetings monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Control Preventionist/Risk Manager, Dietary Manager, Clinical Dietician, Director of Housekeeping, Director of Maintenance, Director of therapy, Director of Human resources, Director of admissions, Director of Business office, Director of Social Services, Director of Activities, MDS (Minimum Data Set) Coordinator, and Consultant Pharmacist. Interview on 7/26/24 at 9:34 AM with the Director of Nursing/Quality Assurance (QA), Administrator/QA; revealed: The QAA Committee meets every month on the second Thursday of the month, the last meeting was held on 07/09/24. The committee consists of the Medical Director, Administrator, DON, Assistant Director of Nursing (ADON), corporate staff, pharmacy representative and all interdisciplinary team members. The focus of QA committee is to review all the departmental reports, anything we notice that is wrong, review how we fix the issues and what to do to improve. We do audits and discuss the interventions at the next meeting to see how well what we put in place is working. Record review of the facility policy and procedure titled Quality Assurance Performance Improvement (QAPI), implemented June 2021 indicates: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Policy Explanation and Compliance Guidelines: 11. Governance and Leadership a) The governing body and/or executive leadership is responsible and accountable for the QAPI program. b) Governing oversight responsibilities include, but are not limited to the following: I. Approving the QAPI plan annually, and as needed. II. Ensuring the program is ongoing, defined, implemented, maintained and addresses identified concerns. III. Ensuring the program is sustained during transitions in leadership and staffing. IV. Ensuring the program is adequately resourced, including ensuring staff time, equipment, and technical training as needed. V. Ensuring the program identifies and prioritizes problems and opportunities that reflect organizational processes, functions, and services provided to residents based on performance indicator data and resident and staff input, and other information. VI. Ensuring that corrective actions address gaps in systems and are evaluated for effectiveness. VII. Setting clear expectations around safety, quality, rights, choice and respect. c) The QAA Committee shall communicate its activities and the progress of its subcommittee PIPs to the governing body (if leadership role is greater than the administrator) at least quarterly, with a formal meeting no less than annually. d) The QAA Committee shall submit supporting documentation of ongoing QAPI activities to the governing body upon request. e) QAPI training that outlines and informs staff of the elements of QAPI and goals of the facility will be mandatory for all staff.

Based on observations, interview, and record review the facility failed to promote and ensure residents are treated in a dignified manner and treated with respect; for four out of the 36 residents sampled. (Resident #201, Resident #159, Resident #48 and Resident #76). As evidenced by 1) staff observed standing while feeding Resident #201 with breakfast. 2)Resident #201 and 159 did not receive their food tray until half an hour after the other two roommates. 3) Staff referred to the residents that need assistance with eating as feeders and 4) Resident #48 in view of staff and other residents was wearing no pants with genitals exposed and Resident # 76 was wearing no socks or shoes propelling in wheelchair around the facility. There were 208 residents residing in the facility at the time of the survey. The findings included: 1) Observation on 07/29/2024 at 12:26 PM trays arrived for residents that ate in rooms, one nurse and three Certified Nursing Assistants (CNAs) started serving trays immediately. Further observation revealed that Resident # 102 and Resident # 159 did not receive their meal trays, but their roommates had received meal trays and were eating. On 07/29/24 at 12:51 PM, Staff A, CNA revealed at the time of the meals depending on the area assigned, she can have one or three feeders that needs assistance. If two feeders are in the same room, after finishing with him/her, the other feeder is assisted. Observation on 07/29/24 at 12:54 PM the tray for Resident #201 was served and assisted with his meal. Observation on 07/29/24 at 12:55 PM the tray for Resident #159 was brought by the kitchen staff. On 07/29/24 at 12:55 PM Staff C, Licensed Practical Nurse (LPN) stated: At the time of the meals all the CNAs have been assigned their section and they assist all the feeders that they have in their section. If there are not enough staff, they have to wait a few minutes. Record review of Resident #201's demographic face sheet revealed an admitted [DATE] with diagnosis that included unspecified dementia. Review of the Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE] section C for cognitive status revealed a Brief Mental Status (BIMS) score of undetermined. Section GG for functional status revealed dependent for eating. Section K for swallowing status revealed no or unknown. Review a care plan initiated on 5/2/2024 and Target Completion Date on 8/23/2023 for diagnosis of Parkinson's and is at risk for injury and decline in function related to tremors and involuntary muscle movements On 07/30/24 at 07:53 AM Staff B was observed standing while assisting Resident #201 with his breakfast; when asked if she knew how to assist the residents with their meals she stated, I always assist the resident standing up, when I do not find a chair. On 08/01/24 at 07:46 AM Resident #159 stated he has been living in the facility for over a year already. He reported: Sometimes it takes a while for the staff to come, I assume it's because they are busy. When they serve the food sometimes some residents had to wait a little longer than usual ones because the staff are busy or there are not enough. Review of Resident #159's clinical records indicated an initial admitted [DATE]. Clinical diagnoses include but not limited to Chronic obstructive pulmonary disease. Review of Resident #159's Significant Change Minimum Data Set (MDS) dated [DATE] section C for cognitive status revealed a Brief Mental Status (BIMS) score of 15 out of 15; indicating Resident # 159 is cognitively intact. 45019 During observation on 07/29/24 at 08:20 AM Resident #48 was in front of room door sitting in wheelchair with no pants on and genitals exposed; Resident # 48 stated: I need some clothes. 07/29/24 at 08:35 AM Licensed Practical Nurse (Staff K) called for help from other staff to get the resident some clothes, no one responded. 07/29/24 at 08:38 AM staff member came to see what Staff K needed. Staff K, spoke with the staff member and they both entered the resident's room to give care. Review of the medical records for Resident #48 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Schizophrenia, major depressive disorder, anxiety disorder, vascular dementia, unspecified severity, with other behavioral disturbance. Review of the Physician's Orders Sheet for July 2024 revealed Resident #48 had orders that included but not limited to: Haloperidol by mouth in the morning and evening related to schizophrenia. Depakene oral solution by mouth two times a day related to schizophrenia. Ativan tablet by mouth at bedtime related to anxiety disorder. Trazodone tablet 1 tablet by mouth every morning and at bedtime related to major depressive disorder. Record review of Resident # 48's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental status score 6, on a 0-15 scale indicating the resident is cognitively impaired. Section E for Behavior documented resident reject evaluation or care one to three days. Section N for medications documented resident is taking antidepressants, antianxiety and antipsychotic medications. Resident #76 On 07/29/24 at 08:40 AM Resident #76 was observed seated in a wheelchair with no shoes or socks on propelling himself around the facility using his feet. Several staff were in attendance on the hallways; at 08:55 AM the Rehabilitation Director brought the resident a pair of blue shoe socks to put on. Review of the medical records for Resident #76 revealed the resident was readmitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Metabolic Encephalopathy Record review of Resident # 76's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental status score 14, on a 0-15 scale indicating the resident is cognitively intact. Interview on 07/31/24 at 07:51 AM assistant Director of Nursing (ADON) stated we need to do an in-service on dignity, making sure staff is documenting the behaviors of the resident, especially in this facility, we have to make sure the residents are being provided the care they need at all times, if the resident is resistant to care we notify the physician (MD) for orders and directions to help aid in the care of the resident. Interview on 07/31/24 at 11:15 AM; the 7:00 AM to 3:00 PM A Wing Certified Nursing Assistant (Staff H) stated: If I see a resident with no clothes, no shoes on, whether the resident is assigned to me or not I will help the patient to get what they need. If the patient is a difficult patient, I will ask someone to help me with the patient. Interview on 07/31/24 at 11:49 AM Certified Nursing Assistant (Staff I) stated: If I observe a resident walking around with no clothes or shoes on, I will take the resident back to their room and dress them and make sure they are taken care of. Interview on 07/31/24 at 12:03 PM; Certified Nursing Assistant (Staff J) from the 7:00 AM to 3:00 PM shift, stated: if I see a resident in the facility walking around with no footwear or clothes on, I will approach the resident, redirect them to their room and put clothes and shoes on the resident. Review of the facility policy titled Promoting and Maintaining Resident Dignity Revision Date 4/2023 states: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. Compliance Guidelines: All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. When interacting with resident, pay attention to treat the resident as an individual.

Based on record review and interviews, the facility failed to permit a resident to return to the facility for one (Resident #2) out of three residents reviewed for admission, transfer and discharge rights. Resident #2 was transferred to the hospital on [DATE], and was not permitted to return to the facility he had lived in since [DATE]. Resident #2 was in the hospital from [DATE] to [DATE]. The resident was ready for discharge from the hospital on [DATE] and was not allowed to return to the facility due to not having a payor source. The deficient practice enabled the facility to initiate a discharge while resident #2 was in the hospital and did not permit the resident to return to his home which created psychosocial harm to resident #2. The findings included: Record review of the facility's policy titled, Transfer and Discharge Requirements (Revised Date ,d+[DATE]) received on [DATE] at 9:37 AM documented: Policy-It is the policy of the facility to transfer and discharge the resident according to state and federal regulations; Procedure-1) The facility will permit each resident to remain in the facility and not transfer or discharge the resident from the facility unless: a) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility, 2) When the facility transfers or discharges a resident under any of the circumstances, the resident's clinical record will include documentation related to the reason for the discharge or transfer, 3) When a discharge or transfer is initiated by the nursing home, the nursing home administrator employed by the nursing home that is discharging or transferring the resident, or an individual employed by the nursing home who is designated by the nursing home administrator to act on behalf of the administration, must sign the notice of discharge or transfer and 9) At least 30 days prior to any proposed transfer or discharge, a facility must provide advance notice of the proposed transfer or discharge to the resident. Subsequent review of another copy of the facility's policy received on [DATE] at 11:26 AM documented: 17) The resident will be permitted to return to the facility upon discharge from the acute care setting. Review of the facility's policy titled, Admission Policy (Issued Date ,d+[DATE]) documented: Policy-It is the policy of the facility to provide admissions according to state and federal regulations; Procedure-1) No potential or current resident will be requested or required to a) Waive any rights afforded by state, local and federal law applicable to nursing facilities. Review of the Demographic Face Sheet for Resident #2 documented, the resident was admitted on [DATE] with a diagnoses of cerebral infarction, atherosclerotic heart disease, chronic kidney disease, hypertension, insomnia, hemiplegia and shortness of breath. The resident was discharged on [DATE] to the hospital, readmitted to the facility on [DATE] and was discharged to the hospital on [DATE]. Review of the Facility assessment dated [DATE] documented: The facility may accept residents with, or residents may develop the following common disease, conditions, physical and cognitive disabilities or combinations of conditions that require complex medical care and management for the following: Heart/Circulatory System (Hypertension, Atherosclerotic Heart Disease), Neurological System (Hemiplegia, Cerebral Infarction), Genitourinary System (Chronic Kidney Disease), Respiratory System (Shortness of Breath); If it is determined that the facility is able to meet the needs of the resident, the individual will be admitted . Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #2 documented, the resident's Mental Status (BIMS) Summary Score was not scored, indicating severe cognitive impairment, required total dependence with one person physical assist for ADLs (activities of daily living) and the resident did not expect to be discharged to the community and will not be returning back to the community. Review of the Physician's Orders Sheet (POS) dated [DATE] through [DATE] for Resident #2 documented, the resident received the following: Oxygen at 2 liters via N/C (nasal cannula) every 8 hours PRN (as needed) for shortness of breath, Trazodone HCL (hydrochloride) 50mg (milligram) tab 1 tab (tablet) PO (by mouth) HS (at night) for insomnia and Plavix 75mg tab 1 tab PO in the morning for atherosclerotic heart disease. The resident had doctor's order for the following: Transfer resident to [ ] local hospital via 911, Diagnosis: Respiratory Distress (dated [DATE]) and Transfer Resident to [ ] local hospital for Diagnosis: Seizure (dated [DATE]). Review of the Resident's #2's discharge care plan dated [DATE] documented the plans were for the resident to remain in the facility. Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #2 documented, the notice was sent with the resident to the hospital on [DATE] with an effective date of [DATE]. The location to which the resident is to be transferred or discharged was a local hospital. The Reason for Discharge or Transfer: Your needs cannot be met in this facility. Okay to transfer resident to [ ] local hospital emergency room via emergency services for evaluation of seizure. The form was not signed nor dated by the resident and the resident was notified verbally. Review of the discharge summary progress note for Resident #2 dated [DATE] at 23:51 documented: Around 11:30 PM, resident noted with seizures. Two episodes of seizures noted. Call placed to [ ] local emergency services. Order received to transfer resident to [ ] local hospital North for active seizures. On [DATE] at 9:38 AM, interview with the Social Services Director. She stated, I am responsible for discharge back to the community ALF (assisted living facility), ILF (independent living facility), home or transfer to another facility. Social services is responsible for discharge care planning. I am not in charge of this discharge because he went to the hospital. His discharge care plan was for the resident to remain in the facility dated [DATE]. On [DATE] at 11:09 AM, interview with the facility's Marketing Director. She stated, My responsibility is as a liaison between the facility and the hospital. I only do clinical. I send the paperwork and the facility let me know if they can take the patient. The resident does not have legal status. The resident had been here for a long time. He came during (Coronavirus Disease) COVID and was working on his legal status and never got it done. He was not discharged back here because we were trying to get documents such as ID (identification) to prove legal status. If the patient doesn't have legal status, he can't come back because there is no payor source. Recently we obtained a social security number but that is not enough. The resident is still in the hospital. [ ] is the Director of Case Management at a [ ] local hospital. We had a conversation with [ ] Director of Case Management since the resident had been in the hospital and we told him we could bring him back with a letter LOA (letter of absence of hospital billing/Letter of Agreement), but [ ], Director of Case Management refused. Last week I spoke to the [ ] Director of Case Management and he wants me to bring back the resident with [ ] health insurance that will cover only 20%. [ ] is in Corporate and she oversees all the facilities for admissions. Record review with the Marketing Director of text messages starting on [DATE] with the Director of Case Management at the local hospital documented the facility agreed to take back the resident with an LOA but the Director of Case Management at the local hospital refused to provide the LOA. When the Marketing Director was asked for clinical documentation between the Director of Case Management at a local hospital, she revealed that the only communication documented was via text messages. On [DATE] at 12:16 PM via telephone, interview with the Regional Director of Marketing and Admissions. She stated, He was able to be readmitted but we requested that he be under the contract with [ ] local hospital. We have a special contract with [ ] local hospital and it entails that they can place a resident who doesn't have insurance, they can do an LOA. Then [ ] the local hospital pays for their stay. I remember this case, I have been in correspondence with [ ] who is at [ ] the local hospital. [ ] said she would look into it. She said [ ] Director of Case Management never called her and asked about the LOA. But I spoke to [ ] and she said she would get back to me. [ ] Director of Case Management at [ ] the local hospital never gave [ ] the information. If they would have said the patient was not eligible for LOA, we would have taken the patient back. We would take the patient back today. On [DATE] at 12:57 PM, during interview with the Admissions Director. She stated, My responsibility is once the Marking Director gets the referral, we take the referral and send it the Director of Nursing to review it. Once we get the approval we then go and run the financial and get an authorization from the insurance. The resident went to the hospital and the case manager from the hospital and the marketing director communicated with text messages that we needed a letter of agreement (LOA). She was the one that communicated with him. We will take the patient back but with a LOA. First time he came he had insurance. He had no insurance when he was here. We took him back when he went out on [DATE] because he went to [ ] another local hospital and we don't have an agreement with them. On [DATE] at 1:10 PM, during interview with the Director of Nursing (DON)(This is the facility's previous DON). She stated, When a resident is transferred to the hospital, we send the labs, list of medications, transfer paper, the bed hold is given and a copy uploaded in the system. On [DATE], around 11:15 resident was noted with labored breathing and congestion. A breathing treatment was given and a call was placed to the medical doctor. A new order was received to transfer resident to a local hospital via emergency services with a diagnosis of respiratory distress. Emergency services arrived shortly after and transferred the resident to the hospital. On [DATE], the resident was readmitted to the facility. On [DATE], around 11:30 PM, the resident was noted with seizures. Two episodes of seizures were noted. A call was placed to emergency services. An order was received to transfer the resident to a local hospital with a diagnosis of active seizures. The resident did not return to the facility. On [DATE] at 1:38 PM, during interview with the Administrator. She stated, I know he was discharged to [ ] a local hospital. [ ] Director of Case Management from [ ] local hospital said that he would be returning with a contract. We have a [ ] local hospital contract for residents that don't have status. The person at [ ] a local hospital wasn't complying with [ ] Director of Case Management who was at [ ] local hospital main campus, which is their internal issue. We are prepared to take him back. We called [ ] local hospital today to tell them we would take the resident back but he was discharged . He was discharged on [DATE] but I do not know where he went. Review of the hospital records for Resident #2 dated [DATE] to [DATE] revealed the local hospital listed over fifty nursing homes contacted between two counties to find placement for the resident after the facility refused to readmit the resident. They couldn't get another nursing home to take the resident until they found someone to become the residents health care proxy. The hospital was able to find the residents daughter and she became his health care proxy and they were able to get another nursing home to accept the resident. Based on the hospital's Social Services notes dated [DATE], the resident had an active discharge order on [DATE]. The hospital was providing the resident PT (Physical Therapy), OT (Occupational Therapy) and ST (Speech Therapy), services the facility could have provided. On [DATE] at 12:04 PM via telephone, interview with the Director of Clinical Resource Department for a local hospital. He stated, Through [ ] a clinical program we send all the clinical information and the referrals. The initial referral goes through [ ] a clinical program. I did communicate with [ ] the Marketing Director through text messages but the communication was mainly through [ ] a clinical program. The issue that I had with this patient, was that this patient was living there for more than two years. I don't know how they were getting paid before and the patient was admitted to [ ] a local hospital and we tried to admit him back and they refused. The answer from the facility for not taking the patient back was the Medicare was inactive and they didn't want to pay for the resident. We reached out to our finance team about the Medicare and because of the resident's status, the residency was not renewed. If the legal status is going to expire, they should have had a social worker renew their status. What they wanted to do was a letter of agreement. For the letter of agreement, [ ] the local hospital pays out of the state taxes. We will pay for the admission to the facility. The patient had [ ] Medicaid. I did not want to give them a letter of agreement because the resident had a payor source which was [ ] Medicaid. We had a lot of back and forth about this patient. Medicare was still active in their system and they felt, they shouldn't have to pay for him. There reason for not taking the resident back was because it was not enough from [ ] Medicaid to cover the skill care for long term for the resident. [ ] Medicaid would not give us authorization. They gave us authorization thirty days later and then I contacted [ ] Marketing Director and the facility refused to take the resident back. We always try to push to send the patient back to where they come from because their belongings are there. We found the daughter in another [ ] state, and she thought her father was deceased . She came to the hospital and now is the proxy for her father. We contacted numerous nursing homes to find placement for the patient but they declined to admit the patient. The patient went to [ ] nursing home. They have an email from [ ] Medicaid. On [DATE] at 11:26 AM, interview and record review with the current DON. He stated, I have been the new DON for three weeks. The Transfer and Discharge Requirements Policy & Procedure dated [DATE] given earlier was revised today to include Number 17: The resident will be permitted to return to the facility upon discharge from the acute care setting. The same policy and procedure received on [DATE] at 9:37 AM, for the Transfer and Discharge Requirements Policy & Procedure dated [DATE] obtained from the Administrator did not include Number 17: The resident will be permitted to return to the facility upon discharge from the acute care setting. On [DATE] at 11:39 AM, interview with the Administrator. She stated, In the Admission, Transfer and Discharge Policy and Procedure, I expect the staff to follow the policy. Basically, what the policy says. If the patient is discharged to the hospital they should be readmitted to the facility. The facility did not complete the paperwork for a facility-initiated discharge, because we did intend to take the resident back. I was not involved in the discharge process, because he went out for a clinical reason, and I was aware of him going out to the hospital. [ ] Staff A, LPN (Licensed Practical Nurse) and the ADON (Assistant Director of Nursing) signed the nursing home transfer and discharge notice on [DATE]. A notice of discharge was not sent to the resident at the hospital while hospitalized . The resident's payor source was Medicare Part A, B and D. Medicaid was pending. Subsequent interview and record review of admissions and discharges from [DATE] to [DATE] on [DATE] at 1:46 PM with the Administrator. She stated, One hundred and twenty eight residents were sent to the hospital and allowed to return during the time period, that the resident [Resident #2] was not allowed to return. He was the only one that didn't return back.

Based on record review and interviews, the facility's administration failed to implement, provide and ensure an effective and efficient discharge process was in place for one resident (Resident #2) out of three sampled residents who were discharged . Resident #2 was transferred to the hospital on [DATE], and was not permitted to return to the facility he had lived in since [DATE]. Resident #2 was in the hospital from [DATE] to [DATE]. The resident was ready for discharge from the hospital on [DATE] and was not allowed to return to the facility due to not having a payor source. The deficient practice enabled the facility to initiate a discharge while resident #2 was in the hospital and did not permit the resident to return to his home which created psychosocial harm to resident #2. The findings included: Record review of the facility's Administration Policy and Procedure (issued ,d+[DATE]) documented the following: It is the policy of the facility to provide appropriate Administration in accordance to State and Federal regulations. Procedure: 1) The facility shall comply with all applicable standards and rules of the agency and shall be under the administrative direction and charge of a licensed administrator, 4) Facility Management is responsible to assist the administrator in overseeing the day to day operations of all departments in the facility, 6) Responsible to monitor each department's activities and communications to elevate performance per facility policies and legal requirements, 11) Develop and maintain written policy and procedures that govern day to day operations of the facility, 14) Ensure resident care is provided in accordance with facility policies and meets professional standards of care and 15) Attend the quality assurance committee, safety meetings as well as other oversight functions to ensure quality resident care. 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 Director of Social Services documented: The Director of Social Services is to plan, organize, develop and direct the overall operation of the facility social services department in accordance with current federal, state and local standards, guidelines and regulations and as directed by the Administrator. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Marketing Director documented: The Marketing Director is responsible for assisting the admissions team in managing referral sources, community outreach, admissions process and marketing programs for the facility, guiding and strategizing a marketing program for services that assures strong relationships with hospitals and payor satisfaction. Review of the Job Description for the Admissions Coordinator documented: The Admissions Coordinator is responsible for obtaining required information and admit residents in an efficient manner in accordance with established facility policies and procedures and as directed by your supervisor. Review of the Job Description for the Bookkeeper/Business Office documented: The Bookkeeper/Business Office is responsible for assisting in the day to day bookkeeping functions of the facility in accordance with current acceptable accounting practices and as directed by the Administrator, Director of Finance or accountant. Review of the Job Description for the Public Relations/Marketing Director known as the Regional Director of Marketing and Admissions documented: The Public Relations/Marketing Director is responsible to plan, develop, organize, implement, evaluate and direct the facility public relations and marketing programs and activities in order to maintain the resident census. Review of the Demographic Face Sheet for Resident #2 documented, the resident was admitted on [DATE] with a diagnoses of cerebral infarction, atherosclerotic heart disease, chronic kidney disease, hypertension, insomnia, hemiplegia and shortness of breath. The resident was discharged on [DATE] to the hospital, readmitted to the facility on [DATE] and was discharged to the hospital on [DATE]. Review of the Facility assessment dated [DATE] documented: The facility may accept residents with, or residents may develop the following common disease, conditions, physical and cognitive disabilities or combinations of conditions that require complex medical care and management for the following: Heart/Circulatory System (Hypertension, Atherosclerotic Heart Disease), Neurological System (Hemiplegia, Cerebral Infarction), Genitourinary System (Chronic Kidney Disease), Respiratory System (Shortness of Breath); If it is determined that the facility is able to meet the needs of the resident, the individual will be admitted . Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #2 documented, the resident's Mental Status (BIMS) Summary Score was not scored, indicating severe cognitive impairment, required total dependence with one person physical assist for ADLs (activities of daily living) and the resident did not expect to be discharged to the community and will not be returning back to the community. Review of the Physician's Orders Sheet (POS) dated [DATE] through [DATE] for Resident #2 documented, the resident received the following: Oxygen at 2 liters via N/C (nasal cannula) every 8 hours PRN (as needed) for shortness of breath, Trazodone HCL (hydrochloride) 50mg (milligram) tab 1 tab (tablet) PO (by mouth) HS (at night) for insomnia and Plavix 75mg tab 1 tab PO in the morning for atherosclerotic heart disease. The resident had doctor's order for the following: Transfer resident to [ ] local hospital via 911, Diagnosis: Respiratory Distress (dated [DATE]) and Transfer Resident to [ ] local hospital for Diagnosis: Seizure (dated [DATE]). Review of the Resident's #2's discharge care plan dated [DATE] documented the plans were for the resident to remain in the facility. Review of the Ombudsman Nursing Home Transfer and Discharge Notice for Resident #2 documented, the notice was sent with the resident to the hospital on [DATE] with an effective date of [DATE]. The location to which the resident is to be transferred or discharged was a local hospital. The Reason for Discharge or Transfer: Your needs cannot be met in this facility. Okay to transfer resident to [ ] local hospital emergency room via emergency services for evaluation of seizure. The form was not signed nor dated by the resident and the resident was notified verbally. Review of the discharge summary progress note for Resident #2 dated [DATE] at 23:51 documented: Around 11:30 PM, resident noted with seizures. Two episodes of seizures noted. Call placed to [ ] local emergency services. Order received to transfer resident to [ ] local hospital North for active seizures. On [DATE] at 9:38 AM, interview with the Social Services Director. She stated, I am responsible for discharge back to the community ALF (assisted living facility), ILF (independent living facility), home or transfer to another facility. Social services is responsible for discharge care planning. I am not in charge of this discharge because he went to the hospital. His discharge care plan was for the resident to remain in the facility dated [DATE]. On [DATE] at 11:09 AM, interview with the facility's Marketing Director. She stated, My responsibility is as a liaison between the facility and the hospital. I only do clinical. I send the paperwork and the facility let me know if they can take the patient. The resident does not have legal status. The resident had been here for a long time. He came during (Coronavirus Disease) COVID and was working on his legal status and never got it done. He was not discharged back here because we were trying to get documents such as ID (identification) to prove legal status. If the patient doesn't have legal status, he can't come back because there is no payor source. Recently we obtained a social security number but that is not enough. The resident is still in the hospital. [ ] is the Director of Case Management at a [ ] local hospital. We had a conversation with [ ] Director of Case Management since the resident had been in the hospital and we told him we could bring him back with a letter LOA (letter of absence of hospital billing/Letter of Agreement), but [ ], Director of Case Management refused. Last week I spoke to the [ ] Director of Case Management and he wants me to bring back the resident with [ ] health insurance that will cover only 20%. [ ] is in Corporate and she oversees all the facilities for admissions. Record review with the Marketing Director of text messages starting on [DATE] with the Director of Case Management at the local hospital documented the facility agreed to take back the resident with an LOA but the Director of Case Management at the local hospital refused to provide the LOA. When the Marketing Director was asked for clinical documentation between the Director of Case Management at a local hospital, she revealed that the only communication documented was via text messages. On [DATE] at 12:16 PM via telephone, interview with the Regional Director of Marketing and Admissions. She stated, He was able to be readmitted but we requested that he be under the contract with [ ] local hospital. We have a special contract with [ ] local hospital and it entails that they can place a resident who doesn't have insurance, they can do an LOA. Then [ ] the local hospital pays for their stay. I remember this case, I have been in correspondence with [ ] who is at [ ] the local hospital. [ ] said she would look into it. She said [ ] Director of Case Management never called her and asked about the LOA. But I spoke to [ ] and she said she would get back to me. [ ] Director of Case Management at [ ] the local hospital never gave [ ] the information. If they would have said the patient was not eligible for LOA, we would have taken the patient back. We would take the patient back today. On [DATE] at 12:57 PM, during interview with the Admissions Director. She stated, My responsibility is once the Marking Director gets the referral, we take the referral and send it the Director of Nursing to review it. Once we get the approval we then go and run the financial and get an authorization from the insurance. The resident went to the hospital and the case manager from the hospital and the marketing director communicated with text messages that we needed a letter of agreement (LOA). She was the one that communicated with him. We will take the patient back but with a LOA. First time he came he had insurance. He had no insurance when he was here. We took him back when he went out on [DATE] because he went to [ ] another local hospital and we don't have an agreement with them. On [DATE] at 1:10 PM, during interview with the Director of Nursing (DON)(This is the facility's former DON). She stated, When a resident is transferred to the hospital, we send the labs, list of medications, transfer paper, the bed hold is given and a copy uploaded in the system. On [DATE], around 11:15 resident was noted with labored breathing and congestion. A breathing treatment was given and a call was placed to the medical doctor. A new order was received to transfer resident to a local hospital via emergency services with a diagnosis of respiratory distress. Emergency services arrived shortly after and transferred the resident to the hospital. On [DATE], the resident was readmitted to the facility. On [DATE], around 11:30 PM, the resident was noted with seizures. Two episodes of seizures were noted. A call was placed to emergency services. An order was received to transfer the resident to a local hospital with a diagnosis of active seizures. The resident did not return to the facility. On [DATE] at 1:38 PM, during interview with the Administrator. She stated, I know he was discharged to [ ] a local hospital. [ ] Director of Case Management from [ ] local hospital said that he would be returning with a contract. We have a [ ] local hospital contract for residents that don't have status. The person at [ ] a local hospital wasn't complying with [ ] Director of Case Management who was at [ ] local hospital main campus, which is their internal issue. We are prepared to take him back. We called [ ] local hospital today to tell them we would take the resident back but he was discharged . He was discharged on [DATE] but I do not know where he went. Review of the hospital records for Resident #2 dated [DATE] to [DATE] revealed the local hospital listed over fifty nursing homes contacted between two counties to find placement for the resident after the facility refused to readmit the resident. They couldn't get another nursing home to take the resident until they found someone to become the residents health care proxy. The hospital was able to find the residents daughter and she became his health care proxy and they were able to get another nursing home to accept the resident. Based on the hospital's Social Services notes dated [DATE], the resident had an active discharge order on [DATE]. The hospital was providing the resident PT (Physical Therapy), OT (Occupational Therapy) and ST (Speech Therapy), services the facility could have provided. On [DATE] at 12:04 PM via telephone, interview with the Director of Clinical Resource Department for a local hospital. He stated, Through [ ] a clinical program we send all the clinical information and the referrals. The initial referral goes through [ ] a clinical program. I did communicate with [ ] the Marketing Director through text messages but the communication was mainly through [ ] a clinical program. The issue that I had with this patient, was that this patient was living there for more than two years. I don't know how they were getting paid before and the patient was admitted to [ ] a local hospital and we tried to admit him back and they refused. The answer from the facility for not taking the patient back was the Medicare was inactive and they didn't want to pay for the resident. We reached out to our finance team about the Medicare and because of the resident's status, the residency was not renewed. If the legal status is going to expire, they should have had a social worker renew their status. What they wanted to do was a letter of agreement. For the letter of agreement, [ ] the local hospital pays out of the state taxes. We will pay for the admission to the facility. The patient had [ ] Medicaid. I did not want to give them a letter of agreement because the resident had a payor source which was [ ] Medicaid. We had a lot of back and forth about this patient. Medicare was still active in their system and they felt, they shouldn't have to pay for him. There reason for not taking the resident back was because it was not enough from [ ] Medicaid to cover the skill care for long term for the resident. [ ] Medicaid would not give us authorization. They gave us authorization thirty days later and then I contacted [ ] Marketing Director and the facility refused to take the resident back. We always try to push to send the patient back to where they come from because their belongings are there. We found the daughter in another [ ] state, and she thought her father was deceased . She came to the hospital and now is the proxy for her father. We contacted numerous nursing homes to find placement for the patient but they declined to admit the patient. The patient went to [ ] nursing home. They have an email from [ ] Medicaid. On [DATE] at 11:26 AM, interview and record review with the current DON. He stated, I have been the new DON for three weeks. The Transfer and Discharge Requirements Policy & Procedure dated [DATE] given earlier was revised today to include Number 17: The resident will be permitted to return to the facility upon discharge from the acute care setting. The same policy and procedure received on [DATE] at 9:37 AM, for the Transfer and Discharge Requirements Policy & Procedure dated [DATE] obtained from the Administrator did not include Number 17: The resident will be permitted to return to the facility upon discharge from the acute care setting. On [DATE] at 11:39 AM, interview with the Administrator. She stated, In the Admission, Transfer and Discharge Policy and Procedure, I expect the staff to follow the policy. Basically, what the policy says. If the patient is discharged to the hospital they should be readmitted to the facility. The facility did not complete the paperwork for a facility-initiated discharge, because we did intend to take the resident back. I was not involved in the discharge process, because he went out for a clinical reason, and I was aware of him going out to the hospital. [ ] Staff A, LPN (Licensed Practical Nurse) and the ADON (Assistant Director of Nursing) signed the nursing home transfer and discharge notice on [DATE]. A notice of discharge was not sent to the resident at the hospital while hospitalized . The resident's payor source was Medicare Part A, B and D. Medicaid was pending. On [DATE] at 11:54 AM, interview with the Business Office Manager. She stated, I have been in this position for a year. My responsibilities are on a day to day to update the census, manage resident trust accounts, Medicaid pending doing the applications and documents needed, update payor trees such as primary, secondary payor sources and request authorization for long term care here in the facility. I collect the documents and [ ] our Medicaid Coordinator was doing the application for Medicaid. I remember [ ] Medicaid Coordinator saying that he had immigration issues and was pending Medicaid for a while until we came up with the charity case. His primary payor source was charity care. Basically, our company came up with this payor source for residents that have issues with legal status. Prior to us coming up with charity care, he was Medicaid pending. At one time he had Medicare. On the face sheet there was a Medicare number for the resident. He was Medicaid pending. We didn't use the Medicare number was because it was ineligible effective [DATE]. The charity case started [DATE]. When he was initially admitted to our facility he was admitted under [ ] Medicaid [ ] which was basically for therapy services. We had four residents, under [NAME] Care and we currently have only three. Subsequent interview and record review of admissions and discharges from [DATE] to [DATE] on [DATE] at 1:46 PM with the Administrator. She stated, One hundred and twenty eight residents were sent to the hospital and allowed to return during the time period, that the resident [Resident #2] was not allowed to return. He was the only one that didn't return back.

Based on observation, record review and interview, the facility failed to follow Infection Prevention and Control Policies and Procedure. This affected 1) One (1) out of 41 residents receiving Accuchecks/blood glucose monitoring (Resident #136). The facility failed to appropriately clean and disinfect a blood glucose monitoring device that was being used for multiple residents. The likelihood existed for cross contamination, increased risk for exposure and being infected with a blood borne pathogen through the use of the contaminated blood glucose monitoring device. 2) Three (3) out of 7 residents on Isolation Precautions (Resident #119, Resident#195, Resident #265). Staff were observed entering resident rooms without putting on proper Personal Protective Equipment (PPE). 3) Two (2) out of 33 residents on the [NAME] unit had a blood appearing substance on the floor and on a blanket (Resident #134 and Resident #9). 4) Two (2) out 33 residents on the [NAME] unit were observed with an overflowing biohazard garbage container with a red bag and an overflowing regular garbage container in their rooms (Resident #136 and Resident #195). At the time of the survey, the facility had 11 residents with diagnoses of Bloodborne Pathogens. This deficient practice had the potential to affect 207 residents admitted to the facility at the time of the survey. Based on the findings with Resident #136 on 3/22/2023, it was determined the findings represented Immediate Jeopardy (IJ) to the health and safety of the residents. After receiving an acceptable IJ Removal Plan, it was determined the IJ had been removed effective 3/23/2023. The findings included: 1. On 03/22/2023 at 8:25 AM, a medication observation was completed with Staff H, Registered Nurse from a staffing agency on the [NAME] Unit/G-Unit. Staff H was observed to take the resident, blood pressure, administer Simethicone 80 mg, 1 tab crushed, via the Percutaneous Gastrostomy Tube (PEG) mixed with 30 cc (cubic centimeters) of water, and gave medication in 60 cc of water, a small amount of medication remained in the medicine cup and 10cc of water was added to give the remaining crushed medication, then the PEG was flushed with 30 cc water. Staff G, Licensed Practical nurse Unit Manager used hand sanitizer, put on gloves, clean Resident #136's finger with an alcohol prep pad, pricked the residents finger and used the [BRAND NAME]multi PERSON USE Blood Glucose Monitoring System. The glucose level was 129. Staff H administered Glargine Insulin Pen subcutaneously into Resident #136 right abdomen. Staff H took the needle off the insulin pen and took it to the medication cart sharps container instead using the sharps container in the resident's room. Staff H was not observed to clean the glucose monitoring device at the resident's bedside and brought the device out of the resident's room and placed it in a top drawer on the medication cart. Staff H signed out the administration of the Simethicone 80 mg, but did not add the glucose level of to the electronic medical record. Staff G, Licensed Practical Nurse (LPN), Unit Supervisor was standing near the medication cart and explained, this was an extra glucose monitoring, and it did not need to be documented. This glucose monitoring was completed to check the glucose prior to administering the Glargine insulin. On 3/22/2023 at 9:15AM, Staff H was asked, Did you clean the glucometer/glucose monitoring device? Staff H replied, she cleaned it. Staff H was asked when she cleaned the glucometer. Staff H replied, stating that she cleaned it while she was in the resident's room. Staff H was asked what she did cleaned it with, and she replied: with an alcohol wipe. When asked to show what she used, Staff H opened the top drawer of the medication cart, and took out an alcohol wipe. Staff G was standing next to the medication cart and intervened and explained to Staff H that this was incorrect. Staff G demonstrated cleaning the glucose monitoring device with the purple top, [brand] Medical and Commercial Disinfecting Wipes for Virucidal, Bactericidal, Fungicidal, Pseudomonad, Tuberculocidal on environmental surfaces. On 3/22/2023 from 9:27AM to 10:34AM, 5 additional residents medication observations were completed on West wing (AC) medication Cart, the (A) wing, the (D) wing, and the East wing. There was no additional glucose monitoring completed during these observations. Review of the facility's policy and procedure for Disinfecting Glucometers dated 4/18/2020 documents, the title of the policy is Cleaning and Disinfecting Policy: It is the policy of the facility to clean and disinfect multi-patient use blood glucose meters. Resident to resident transmission of blood-borne pathogens is a well-known risk when using lancets, needles, and syringes. Blood glucose monitors that are shared among residents must be cleaned and disinfected. Procedures: 1. Apply gloves before performing a blood glucose test. Glucose monitoring, administration of insulin, and any other procedure that involves potential exposure to blood or body fluids. 2. Dispose of used finger stick devices and lancets at the point of use in an approved sharps container. Do not reuse needles, syringes, or lancets. 3. Remove gloves and wash hands. 4. Apply new gloves. 5. Thoroughly clean and disinfect all visible soil or blood from glucometer with Sani-cloth. 6. If the Resident has C-Diff, thoroughly cleans, and disinfect all visible soil or blood from glucometer with PDI Orange Top Sani-Cloth Bleach Wipes. 7. Perform hand hygiene (i.e., hand washing with soap and water or use of an alcohol-based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on other residents. 8. Follow manufacturer's guidelines for cleaning and disinfecting of glucose meters. Specific guidelines for glucose meters may vary with the manufacturer. Keep glucometer wet for maximal kill time indicated on disinfecting agent product label. 9. In the absence of manufacturer's recommendations, the glucometer is considered a semi-critical device, follow policy for cleaning semi-critical devices. NOTE: When selecting a disinfecting cleaning product, review the required contact time. Nursing is to understand and demonstrate the necessary length of time the disinfectant must be in contact with the glucometer. Each disinfectant has specific instructions. You may have multiple shared glucometers which are alternated between clean and disinfection status (i.e., Glucometer 1 is in use and then while glucometer 1 is being disinfected, glucometer 2 is in use.) Staff H did not follow the facility's policy and procedures for Cleaning and Disinfecting Blood Glucometer. Review of the blood glucose monitoring machine manufacturer's instructions revealed, Caring for the system documents, To minimize the risk of transmission of blood borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below. After disinfection, users should remove gloves and wash hands before testing the next patient. And other body fluids on the exterior of the meter and lancing device before performing the disinfection procedure. The disinfection procedure is needed to prevent transmission of blood borne pathogens. The meter should be cleaned and disinfected after use on each patient. The Blood Glucose Monitoring system may only be used for testing multiple patients on Standard Precautions and the manufacturers disinfection procedures are followed. Any disinfectant product containing these EPA registration numbers may be used on this device. Cleaning: 1. Wear appropriate protective gear such as disposable gloves. 2. Open the cap of the disinfectant container, pull out wipe. 3. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 4. Dispose of the used towelette in the trash bin. The meter should be cleaned prior to each disinfection step. Note: No actual drying off the meter is required before starting the disinfecting procedure. Disinfecting: 5. Pull out 1 towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a new towelette to remove blood borne pathogens. 6. Dispose of the used towelette in a trash bin. 7. Allow exteriors to remain wet for the corresponding contact time for each disinfectant. 8. After disinfectant, the users gloves should be removed to be thrown away and hands washed before proceeding to the next patient. Staff H did not follow the manufacturer's instructions for cleaning and disinfecting the facility's [Company/Brand Name] Multi, Blood Glucose Monitoring System. 2. Observation on 3/20/2023 at 6:27AM revealed Resident #195 and Resident #265, had a blue Stop sign and Special Droplet/Contact Precautions sign on their doors. The sign gave directions for only essential personnel should enter the room. Everyone must clean hands when entering and leaving the room. Wear a NIOSH [National Institute for Occupational Safety and Health] approved N95 or equivalent or higher-level respirator at all time, wear eye protection, gown, and glove at the door. A cart with Personal Protective Equipment was observed next to Resident #265's door. At 6:36 AM, Staff P, a Certified Nursing Assistant (CNA) was observed to enter Resident #265's room without a gown and gloves. Staff P was wearing a mask. Observation on 3/20/2023 at 6:55AM, Staff Q, a C N A was observed to go partially enter into Resident #195's room. Staff Q was observed to be wearing an N 95 mask, the staff member was not observed to use hand sanitizer or to put on a gown. Observation on 3/20/2023 at 7:56 AM, Staff Q entered Resident #195's room without putting on a gown. Staff Q was observed to come out of the room and put on a gown and went back into Resident #195's room. 3. Observation on 3/21/2023 at 7:29 AM in Resident #134's room, an alcohol wipe was observed on the floor, and it appeared to have blood on it. 4. Observation on 3/21/2023 at 8:07 AM, the biohazard garbage container with a red bag was overflowing with garbage in Resident #136's room. 5. Observation on 3/21/2023 at 8:19AM, a blood appearing substance was observed on Resident #9's blanket. 6. Observation on 3/21/2023 at 9:01 AM, Resident #119 had an isolation sign on the door with a stop sign, Modified Contact Precautions Everyone Must: Staff to sanitize hands before entering & upon exiting. Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect shared equipment with bleach wipes. Resident #119 was diagnosed with Candida Auris. The Maintenance Director was observed to walk into Resident #119's room without sanitizing hands, and putting on a gown. The Maintenance Director was observed to leave the room without sanitizing his hands. On 3/21/2023 at 10:03 AM, the Maintenance Director was interviewed about entering Resident #119's room with no PPE. The Maintenance Director reported they are replacing the resident's mattress. He did not see the isolation signs until he was walking out of the door. He reports, he went to the nurses station about the door being open. The nurse told him the resident had been in isolation for over 10 days. On 3/22/23 at 1:15PM, Staff G, LPN, and Unit Supervisor was informed about staff entering the rooms of residents on isolation precautions without PPE for Resident #119, Resident #195 and Resident #265. On 3/22/23 at 1:45 PM Staff G , unit Managerreported Staff H had never worked on her unit before. Staff H had worked on other units. Staff G reports this morning she was trying to orient Staff H, but Staff H had already started taking care of the residents. Staff G reports, she was talking to Staff H about the type of residents on the unit. The unit was noted to have residents with tracheostomies, PEGs, and residents on isolation precautions. 42532 7. On 3/20/2023 at 6:00 AM, upon entrance into the facility and during tour of the facility a strong urine odor was noted. During an observation on 3/24/2023 at 10:45 AM, a strong urine odor was noted on the G Wing. The surveyor knocked on Resident # 146's door and the resident responded yes, and the surveyor entered the room. Upon entering the room, the floor was noted to be covered in urine and Resident # 146 was standing by the bed urinating on the floor. The nurse was notified, and she called the housekeeping immediately. During an interview with Staff G, a Licensed Practical Nurse (LPN) /UnitManager on 03/24/2023 at 11:20 AM; Staff G stated that Resident # 146 urinated on his room floor many times. She encouraged him to call for assistance every time he was going to go to the bathroom, but he continued to do it. The resident had behaviors and there was no way to redirect him. Review of the facility's Infection Prevention and Control Program policy and procedure dated 6/2020, revised on 9/29/2021 revealed in part, Policy: It is the policy of the facility to ensure that the Infection Control Program is designed to prevent, identify, report, investigate and control the spread of infections and communicable disease for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement; provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with State and Federal Regulations and national guidelines. The Procedures included, but was not limited to: 1. The facility will establish and maintain an infection prevention and control program under which it: a. Prevents, identifies, reports, investigates, and controls the spread of infections and communicable disease in the facility. b. Conducts surveillance for early detection of infections, clusters/ outbreaks, and reportable diseases and to track and trend surveillance data. c. Decides when and how isolation should be applied to an individual resident. d. Prohibits staff with a communicable infection or disease or infected skin lesions. from direct contact with residents or their food, if direct contact will transmit the disease/infection; and e. Maintains a record of incidents and corrective actions related to infection. prevention and control. f. Ensure compliance with state and federal regulations regarding infection control. 45019 During an interview on 3/24/2023 at 8:02AM, the Infection Preventionist (IP), Registered Nurse stated, I have been the Infection Preventionist for over a year now at this facility. I have done re-education with all nurses on how to clean, disinfect and sanitize the glucometer properly and the right product to clean with. Some of the staff refer to the cleaning products as alcohol instead of Sani-wipes. On 3/22/2023, and 3/24/2023 we started training all our nursing staff on the cleaning, disinfecting, and sanitizing of the glucometers, all our in-house nursing staff have been trained. Our agency nurses receive training over the phone and as they come to the facility for an assignment before they start working. The cleaning product that we are using to clean, sanitize and disinfect the glucometers is an approved product by the manufacturer of the glucometers according to the instructions. The Infection Preventionist reported regarding the residents on transmission-based precautions, the facility has 3 residents on contact precautions for Candida Auris, 1 resident on contact precautions for Disseminated Mycobacterium Intracellular Complex (DMAC) and 3 residents on droplet precautions for Covid-19 precautions/new admission. The rooms that residents on transmission-based precautions are in have the appropriate signage on the door, personal protective equipment by the room for staff to use, and biohazard bins in the room for disposal of PPE. The residents on transmission-based precautions are not on modified contact precautions, anyone that enter these residents' rooms must wear the full personal protective equipment provided (gowns, gloves, face shield, N95 mask) and dispose of used PPE in the biohazard bin in the room prior to exiting. The residents on transmission-based precaution for Candida Auris will be on contact precautions for as long as they are in the facility. The residents on transmission-based precaution for COVID-19 precautions will be on droplet precautions for 10 days. All staff are trained in the correct use of personal protective equipment, Infection control education to the staff at the facility is ongoing and is completed monthly. The Infection Preventionist stated that staff are monitored for compliance regarding wearing personal protective equipment and handwashing by doing random observations of staff while they are actively working with residents on the units. If the observed staff is performing a task incorrectly, corrections and re-education are made immediately. The corrections/re-education is also discussed at our weekly meetings and monthly quality assurance meetings. The facility's approved IJ Removal Plan was verified as completed on 3/24/2023, with the IJ Removal effective on 3/23/2023. The following was verified: On 3/22/2023, the Charge Nurse interceded and reviewed the policy with the Staff H, RN. The glucometers were removed from the cart, cleaned, and disinfected and the drawer for the glucometers was cleaned and disinfected. On 3/22/2023, Staff H was removed from her assignment and the staff agency was notified. On 3/22/2023, the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) checked the carts and confirmed the appropriate disinfectant wipes were available to clean the glucometers. On 3/22/2023, the DON, ADON and Infection Preventionist, began retraining all licensed nurses currently working including agency nurses using the facility policy for cleaning the glucometers and validating the training with return demonstration using a competency compliance audit tool which includes the steps that need to be implemented to reduce the risk for transmission of blood borne pathogens. Only nurses who successfully pass the validation competency will be allowed to work. On 3/22/2023, the DON/ADON reviewed the list of diagnoses of the resident with an order for blood glucose monitoring. There was only one resident on the nurse's assignment with orders for blood glucose monitoring. No residents on her assignment were noted with a diagnosis related to blood borne pathogens. An Inservice for the 3:00 PM to 11:00 PM and 11:00PM to 7:00 AM licensed nurses to be conducted by the clinical nursing staff utilizing the facility glucometer cleaning policy and procedure by a return demonstration validation competency. The nurses must successfully complete the competency as a return demonstration of the in service provided prior to beginning the med pass. The licensed nurses were educated to follow manufacturer's guidelines regarding the contact time of the disinfecting product. The licensed nurses will keep the glucometer wet for maximal kill time indicated on the disinfecting agent product label. Glucometers that have been cleaned and disinfected will be placed in a plastic bag and placed in the top drawer of the medication cart. On 3/22/2023, all licensed nurses on the 3:00 PM to 11:00PM shift were re-educated at the beginning of the shift by the Infection Preventionist. All nurses successfully completed their return demonstration competency as validation of the teaching provided. On 3/22/2023, a log for contracted nursing agency staff was created which is to be maintained at the receptionist desk to confirm agency staff scheduled to work has received the contracted staff orientation and has also received education on the facility glucometer cleaning policy and procedure, followed by a return demonstration competency to validate education received. Agency staff who have not received orientation will be educated prior to beginning their shift. On 3/22/2023, an Ad Hoc Quality Assurance meeting was held, members present included the NHA/RM (Nursing Home Administrator/Risk Manager), DON, ADON, Social Services Director, Infection Preventionist, Unit Managers, Activity Director, MDS (Minimum Data Set) Coordinator, Regional Director of Clinical Services, and the alternate Medical Director. The performance improvement plan was approved at the Ad Hoc meeting. On 3/22/2023, the licensed nurses 11:00 PM to 7:00 AM shift were re-educated by the nursing supervisor on the glucometer cleaning policy and return demonstration to validate education received. On 3/23/2023, the licensed nurses on the 7:00 AM to 3:00 AM shift were re-educated by the Infection Preventionist/designee on the glucometer policy followed by a return demonstration competency. The nurse manager/supervisor or designee on each unit will review the daily schedule to ensure all licensed nurses including agency nurses have received glucometer cleaning training and successfully completed the return demonstration competency prior to beginning their med pass. Any clinical nursing staff identified by the nurse manager who has not received the training will be trained prior to beginning their shift. Newly hired clinical nursing staff will receive training during their general orientation. To validate the education received and successful completion of return demonstration competencies is followed the DON, ADON, Infection Preventionist designee will observe licensed nurses including agency nurses cleaning the glucometer to ensure the licensed nurses follow the facility infection control policy. The Infection Preventionist, ADON or designee will make daily rounds and observe infection control practices of the areas listed above to ensure the staff follow the facility infection control guidelines. For staff who fail their observation are to be immediately re-educated and required to complete the training/competency checklist. As of 3/23/2023 44 out of 55 licensed nurses employed have been educated and successfully completed the return demonstration competency validation. Eleven out of 55 licensed nurses were contacted by phone to be educated on the facility glucometer cleaning policy and gave a verbal demonstration over the phone. The nurses who were educated by phone will have a hands-on demonstration conducted prior to beginning their shift. 100% were educated in person or by phone. The facility currently uses 5 agency nurses in which all 5 nurses have been educated on the cleaning policy and successfully completed return demonstration to validate education received. The Infection Preventionist/designee will observe at least 6 nurses cleaning the glucometer each shift daily for 2 weeks, then weekly for 4 then monthly for 2 months.