Health inspection·May 10, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews, the facility failed to prevent the neglect of one (Resident #1) out of four residents sampled during the time of this survey. The facility's staff failed to supervise and implement adequate measures to prevent the elopement of Resident #1 who was coded as an elopement risk. The facility neglected to adequately monitor and address Resident #1's displayed exit seeking behaviors and intent of elopement. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate alert monitoring system was in place allowed the resident to elope undetected by staff on 5/03/23 at 10:32 AM. The resident was not located until 6:10 PM on 5/05/23 wandering in a neighborhood 17.1 miles from the facility by law enforcement who reported Resident #1's location to the resident's son. There were 107 residents residing in the facility at the time of the survey. Refer to F 607, F 689 and F 835. The scope and severity for F600 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of 5/10/23. The scope and severity was lowered as a result of the facility's removal of immediate jeopardy actions implemented as of 5/10/23. The facility continued to have noncompliance at a lower scope and severity. These corrective actions were verified by the survey team through observation, record review and interview on 5/8-10/23. The findings included: Record review of the facility's policy titled, Freedom from Abuse, Neglect and Exploitation protocol implementation date was on 11/2017, 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 and corporal punishment of any type by anyone. Neglect means failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. A prompt thorough investigation will be conducted by the facility immediately. Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with diagnoses of dementia, psychosis, mood affective disorder, muscle weakness and unsteadiness on feet. Review of Resident's #1 Elopement care plan dated 4/15/22 documented the resident is an elopement risk related to impaired safety awareness. Resident is refusing to wear his wander guard; Goal: Resident will not leave facility unattended and he will wear the wander guard throughout the review date; Page 1 of 32 105120 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Apply wander guard; Elopement assessment to be completed; Take photo and place in the elopement book. Review of the progress notes documented the following: Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Nursing staff reported that resident was not in his room; Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Surrounding area outside the facility was initiated on foot and vehicle; Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Immediate search of the premises done, unable to locate the resident. Director of Nursing made aware. CODE GREEN announced to staff and complete search initiated; Dated 5/03/23 time stamped 18:15-No type specified: Late entry-Administrator was notified; Dated 5/03/23 time stamped 19:18-No type specified: Late entry-Local police notified. Daughter and son were notified; Dated 5/03/23 time stamped 19:30-No type specified: Late entry-MD was notified; Dated 5/03/23 time stamped 19:35-No type specified: Late entry-Immediate complete head count initiated of all residents. No other elopements identified; Dated 5/03/23 time stamped 20:00-No type specified: Late entry-Head count by nurses 3 times a shift initiated; Dated 5/03/23 time stamped 20:00-No type specified: Late entry-Elopement books audited and in all nursing stations, reception area, back patio area; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Son visited facility and spoke with management. Emotional support provided; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Education on abuse, Neglect Policy and Procedure initiated; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Education to all staff on Elopement policy and Procedure initiated; Dated 5/03/23 time stamped 20:34-No type specified: Late entry-Situation Background Assessment Recommendation (SBAR) Summary for Providers: Dementia, Resident eloped; Dated 5/03/23 time stamped 20:45-No type specified: Late entry-Call placed to local agency [ ] report taken; Dated 5/03/23 time stamped 20:48-Alert Note: Resident awake, alert, oriented and ambulated without assistive device, under elopement watch. Around dinner time, was looking for resident when he was unable to be located. Search initiated by all staff, resident still not able to located. Responsible party and MD made aware of the incident. Local police [ ] also notified. Search continues for resident by all staff in the facility and off the facility with no positive result. Search is ongoing until resident is found; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Re-assessment of Elopement Risk Assessments initiated by nursing for all current resident; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Search of the surrounding area continue by staff on foot and by vehicles; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-All doors and exit doors checked by Maintenance staff; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-For residents identified as Elopement risk. Placed on hourly checks; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Staff assigned to call area Hospital emergency room in an attempt to locate the resident; Dated 5/03/23 time stamped 21:27-Health Status Note: Resident woke up and ate 100% breakfast, morning meds administered. He self ambulates, on close monitoring due to constant exit seeking behavior; Dated 5/04/23 time stamped 08:00-No type specified: Late entry-Local Hospital emergency room contacted in effort to locate the resident; Dated 5/04/23 time stamped 11:00-No type specified: Late entry-Staff continue to call local hospital emergency room to locate the resident; Dated 5/04/23 time stamped 15:00-No type specified: Late entry-Local hospital emergency rooms contacted in effort to locate residents; Dated 5/05/23 time stamped 08:00-No type specified: Late entry-Local hospital emergency rooms contacted in effort to locate resident; Dated 5/05/23 time stamped 16:40-No type specified: Late entry-Police officer informed the administrator that resident was found [ ] local city; Dated 5/05/23 time stamped 16:47-Order Note: Resident's family was notified that the resident was found by police officer in [ ] local city. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for March 2023, April 2023 and May 2023 105120 Page 2 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few documented the resident was receiving the following medications: Valproic Acid Solution 250mg (milligrams)/5ml (milliliters) give 10ml PO (by mouth) BID (twice a day) a day for mood stabilizer; Quetiapine Fumarate 100mg tab (tablet) 1 tab PO BID for psychosis and Nitroglycerin 0.4mg tab 1 tab sublingually every 5 minutes PRN (as needed) for chest pain x (times) 3 doses (Started on 5/05/23). Medications were given as ordered by the medical doctor. The resident received medications on 5/03/23 at 9:00 AM but did not receive meds at 9:00 PM due to missing out of the facility. The resident had an order for a wander elopement alarm bracelet on 4/15/22 and was discontinued on 3/15/23. Review of the Elopement Risk Assessment/Evaluation dated 3/26/23 and 4/05/23 documented: The resident is at risk for elopement; Resident had verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors and Ambulates independently with or without the use of an assistive device. During a telephone interview with Resident's #1 daughter on 5/06/23 at 11:43 AM via telephone. She stated, The dispatchers found my father in [ ] local city. He is at the hospital now. My older brother is the POA (power of attorney) and has more that he can tell you. During a telephone interview with Resident's #1 son on 5/06/23 at 11:49 AM via telephone. He stated, My father was found in the city of [ ] near [ ] local city. He was found on yesterday, Friday and missing since Wednesday. He was missing for over 48 hours. I filed a missing person's report with the [ ] local city. My father was aware that he traveled far. He has a case of early dementia. I transported him to a [ ] local hospital and he is currently there. He was missing since Wednesday morning around 10:00 AM. Video footage showed my father leaving the facility on foot and my sister was contacted around 7:30 PM in the evening. On 5/08/23 at 11:25 AM, the Director of Nursing (DON)/Risk Manager/QAA (Quality Assessment and Assurance) stated, On 5/03/23, according to the nurse [Staff A, Licensed Practical Nurse (LPN)] at 5:45 PM she couldn't locate the resident in his room. They checked room to room on unit three with the help of other staff that was here. They also searched on Unit 1 and Unit 2 and outside on the premises. They couldn't find the patient. The patient was ambulatory, come to Unit 1 and go out to the patio and enjoyed participating in activities. At 6:00PM they confirmed the patient could not be found in the building. Immediately, they activated CODE GREEN our code for elopement. We searched again the area, informed the Administrator and informed all my interdisciplinary team to come back to the facility to look for the patient. At 7:18 PM, we called the police and the son and the daughter. Somewhere between 7:30-7:35PM, we did a complete head count of every resident in the building to verify if anyone was missing. Everyone was here, except the resident. At 8:13 PM, the son came to the facility and we gave him emotional support and told him what transpired. At 8:30 PM, the staff came back to the facility from searching and we started the education on elopement and on abuse and neglect. Around 8:45PM, we reported to [ ] local agency about the incident. We initiated the [ ] local Immediate Report by the Social Services Director. At 9:00 PM, we assigned a staff to call all emergency rooms in the area to find the patient. We checked all exit doors around that time. We continued searching for the resident. The nurses did reassessments for all residents at elopement risk. He was considered an elopement risk. He was able to remove the wander guard and the doctor discontinued the order for the wander elopement alarm. Some staff went about searching until 2:00AM in the morning and I continued searching until 5:00 AM in the morning. We identified four residents who were elopement risk but one had expired over the weekend. All elopements books were audited and updated. I gave instructions to do head count three times every shift (in the morning when they come in, 4 hours after that and before they leave for the day and then endorse it to the next staff). On 5/04/23 at 8:00 AM we started replacing the fence on the back patio because it was short and we replaced another gate on the 105120 Page 3 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few back patio on yesterday. We now have the security guard who started on 5/05/23 to keep an eye on the back patio. We called the emergency rooms to locate the resident. We continued the education on elopement and abuse and neglect policy and we did an elopement drill. At 3:00 pm on 5/05/23 we continued to call the hospital emergency room. Around 8:00PM, the residents son came to talk to me and the Administrator. On 5/05/23, at 5:00 PM, the security guard company sent a guard to be stationed on the back patio. Security guard will be on the back patio for 24 hours, seven days a week. CNA will be assigned to be outside on the front patio 24 hours, seven days a week. At 4:40 PM, the police officer called the Administrator that the resident was found in [ ] local city. He was knocking on peoples doors in the neighborhood where he was found. At 4:45 PM, I called the family, the son and told him the father was found by a certain police officer and he went to the [ ] local city to pick him up. Around 7:00PM, I called the son and he said the father is with me and we are on our way to the facility. He took him to eat something first and he said he wanted his father to go the local emergency room (ER) for evaluation. At 8:35PM, resident arrived in the company of his son. We readmitted the resident, reassessed him, offered fluids, food, ADLs and medications. We put him on 1 to 1. When he came back he was dirty, we tried to get him to take a shower but he refused. We asked the son to help us get him cleaned up. At 10:35 PM he was sent out to the [ ] local hospital ER for evaluation with the son by his bedside. Before this incident, the door to the back patio off Unit 2, the residents were able to push the door and go outside, there was no alarm. On 5/03/23, we started working on upgrading the door and the alarm system and it was not finished until mid-afternoon 5/04/23. The resident went outside the back door off of Unit 2. The back door off the Unit 2 now has an alarm and code. Only the staff has the code. We plan on changing the code every 2 months and we are checking doors everyday by the Maintenance Director. On 5/08/23 at 11:58 AM, the Administrator stated, There was an elopement, we did a search of the area. We called the police and let them know about a missing person, we let the family and the physician know. The police came and gave us the paperwork for the missing person. We started doing drills that night into the weekend and on elopement, abuse and neglect. On Friday 5/05/23 we got the call that he had been found. The police brought him back. He was then sent to the hospital for evaluation. Staff will be back to work on Wednesday, 5/10/23. I am not able to pull the footage because it overrides. I didn't get a chance to take still photos of the video. On 5/08/23 at 12:06 PM, the Social Service Director stated, On Wednesday about 5:45-5:50PM, the nursing staff reported that the resident was not in the building. The nursing staff as well as the managerial staff conducted an in-house search for the resident, we could not find him in the facility. Therefore, staff went out on foot, our cars to check the surrounding areas. We came back, we were not able to find the resident. We notified the police, doctor, family member. We continued to search for him. We called the hospitals in the area and no one found him. The police came and spoke with me, they met with the nursing staff assigned to the resident. I called [ ] local agency to make them aware and reported it. Friday afternoon about 4:40PM, the Administrator received a call from [ ] local police had found the resident. The resident returned to the facility around 7:00PM accompanied by his son. He was assessed by the nursing staff, the physician was made aware that the resident was found and the son and physician were in agreement for him to be sent to [ ] local hospital for further evaluation. On 5/08/23 at 3:33 PM, Staff C, Registered Nurse (RN) for the 3:00 PM to 11:00 PM shift stated, When I came in on 5/03/23 I did my rounds on Unit 1 and Unit 2. I was going up to Unit 3 and met the C N A (certified nursing assistant) in the elevator and she told me she noticed he was missing. We started looking in bathrooms, rooms, dining room, trash rooms, med rooms. When we didn't see him, I pulled his chart he was not signed out by any family member. I came and told the 105120 Page 4 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few DON and he called Code Green. We looked on all units, the patio, the DON informed the family and police. I was so frantic I got in my car and drove around looking for the resident. I drove around for 2 ½ hours looking for him and I didn't find him. When I came back, the police was here. On 5/05/23, I started the assessment and tried to clean him up. He was dirty and he had a smell. He didn't want us to clean him up, he went out of the room and said if you keep bothering me, I will go back downstairs to my son. The son came up and calmed him down, and he let us clean him. The son wanted him to go out to a [ ] local hospital for evaluation. We had put one to one in place for when he came back to the facility. No injuries were noted, he had very dry skin and redness were noted. Transportation came and the son left with the resident to the hospital. On 5/09/23 at 8:23 AM, the Social Services Director stated, I was at the nurses' station with the nurse and I dialed the number for the son. We called the son, the voicemail was full and we could not leave a message. Then we proceeded to call the daughter who answered and the nurse told her about the incident. The resident's vision was impaired, he has cataracts. He did not have glasses. He had a Vision consult on 4/17/23 and the consult says he has cataracts. On 5/09/23 at 8:31 AM, Staff D, Licensed Practical Nurse (LPN), Unit Manager 3 for the 7:00 AM to 3:00 PM shift stated, Like any other day, he ambulates. He likes to talk to other Spanish speaking residents. He goes downstairs to activities. Everyone in the building is aware that we need to keep an eye on him. There is nothing that is on a time schedule, the main thing is to keep him from the front door. He always talks about going to the bank. The week before he left and I told him he has money here. He went to the Business Office and they gave him $20.00 and he would carry it in his pocket. This was 8 days before he left. As far I know he didn't have any vision problems. As far I knew he was here in the facility all day. I saw him around 10:00 AM. I had already left for the day and they notified me he was missing because he didn't show up for dinner. I got in my car and came back immediately. I drove around the neighborhood looking for him. He went out the back door on Unit 2, took a chair, took off his shoes and used his toes to get in the grooves of the fence and climbed over. On 5/09/23 at 8:39 AM via telephone Staff A, LPN for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, I took his vital signs and gave him medications around 9:30 AM. He ate his breakfast. He walks up and down and goes downstairs on the patio. I didn't have to give him his medications until 1:00pm. He received medications at 9:00 am and 5:00pm. The C N A put his lunch tray in his room and she did not go back to see if he ate or not. She removed the lunch tray when it was time to give him his dinner tray. That's when she realized that he was missing. She came to me and said she didn't see him. I asked her did he eat and I saw his lunch tray. I said he didn't he eat and she said no. We went room to room. I called the supervisor and told him. I went in my car and rode all around and he was nowhere to be found. I can say the incident was negligence. I was praying that he would be found alive and God answered my prayers. On 5/09/23 at 8:47 AM via telephone Staff B, Certified Nursing Assistant (CNA) for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, When I came on Wednesday to work I saw all my patients. I gave him his breakfast and he eat and I took up his tray. I put his lunch tray in the room because he was downstairs. He would come and eat the food. I went to the other patients and was taking care of them. Sometimes he would eat in the dining room upstairs. I have 11 patients to care of and he didn't listen. I tell him not to go downstairs, he don't listen to you. The camera showed he left at 10:30 AM. I was working a double shift on that day. When I put the dinner tray, I saw the lunch tray there and I said where is he. I don't see him. I went to the nurse and we started checking for him. 105120 Page 5 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few On 5/09/23 at 9:03 AM, the Human Resources Manager stated, We couldn't see much because of the site where he jumped. He pulled a chair, to the fence and jumped over the fence. The incident occurred according to the video around 10:37 AM. It was so quick. There was not much evidence on the video. We didn't get a clear picture of him because the camera didn't get the side of the patio. On 5/10/23 at 10:06 AM, the Business Office Manager stated, He had a personal funds account and his check started coming here about a month ago. He came to me on 4/25/23 and he received $20.00. The facility's immediate jeopardy removal plan included the following information: The staff were In-serviced/trained on 5/03/23 for 3PM-11PM shift, 11PM-7AM shift for nurses and certified nursing assistants (CNA) and 5/04/23 for 7AM-3PM shift, 3PM-11PM shift and 11PM-7AM shift for nurses and CNAs regarding: Wandering precautions and wander/elopement alarm device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. On 5/4-7/23 on all shifts for nurses, cnas and all staff were in-serviced/trained on an elopement drill and abuse and neglect. A 24-hour security guard was brought in to monitor the back exits. The facility installed an alarm system that is audible at the nursing station and care areas were added to the exit door on Unit 2, to alert the staff of any residents trying to exit the door. Maintenance staff or their qualified designees, conduct daily door audits to ensure all door are in proper working order, including checking that the alarm is audible at the nursing station and care areas. A 6-foot fence was installed to the back end of the smoking area, to ensure that residents remain in the smoking area. The gate will be monitored by the patio area's CNA or designated staff member. A security guard has been assigned to watch the north-west gated area during the ongoing updates to the facility's security systems. An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code green, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on 5/03/23 for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor the north-west gated area exits. Prompt re-training was initiated on 5/04/23 for all shifts regarding Abuse Reporting, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1, Close Monitoring and Code Green. The immediate jeopardy removal plan was verified as completed from May 8 - 10, 2023 by reviewing the above documentation; observing the back patio; observing the coded, audible alarm exit door on Unit 2; interviewing the security guard on the back patio; interviewing (16) staff members to verify they received elopement inservices, participated in elopement drills, inservice on checking wander guards, abuse and neglect inservices. The verification included RN's, LPN's, and CNA's from the 7-3, 3-11 and 11-7 shifts. Reviewed inservices and sign in sheets for: Date - 5/03/23; Title of the In-Service: Elopement Drill; Audience: All staff Date - 5/04/23; Title of the In-Service: Elopement; Elopement Drill; Audience: All staff 105120 Page 6 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0600 Date - 5/04/23; Title of the In-Service: Neglect; Audience: All staff Level of Harm - Immediate jeopardy to resident health or safety Date - 5/05/23; Title of the In-Service: Neglect; Audience: All staff Residents Affected - Few Date - 5/6-7/23; Title of the In-Service: Neglect; Audience: All staff Date - 5/05/23; Title of the In-Service: Elopement Drill; Audience: All staff Date - 5/6-7/23; Title of the In-Service: Elopement Drill; Audience: All staff 105120 Page 7 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 #1) out of four residents sampled during the time of this survey. This deficient practice has the potential to affect all 107 residents residing in the facility. This enabled resident #1 to elope from the facility undetected on 5/03/23 at 10:32 AM. The resident was not located until 6:10 PM on 5/05/23 wandering in a neighborhood 17.1 miles from the facility by law enforcement who reported Resident #1's location to the resident's son. Residents Affected - Few The scope and severity of F607 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of 5/10/23. The scope and severity was lowered as a result of the facility's removal of immediate jeopardy actions implemented as of 5/10/23. The facility continued to have noncompliance at a lower scope and severity. These corrective actions were verified by the survey team through observation, record review and interview on 5/8-10/23. Refer to F600, F689, F835 and F867. The findings included: Record review of the facility's policy titled, Freedom from Abuse, Neglect and Exploitation protocol implementation date was on 11/2017, 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 and corporal punishment 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. Compliance Guidelines: 1) The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with a diagnosis of dementia, psychosis, mood affective disorder, muscle weakness and unsteadiness on feet. Review of Resident's #1 Elopement care plan dated 4/15/22 documented the resident is an elopement risk related to impaired safety awareness. Resident is refusing to wear his wander guard; Goal: Resident will not leave facility unattended and he will wear the wander guard throughout the review date; Apply wander guard; Elopement assessment to be completed; Take photo and place in the elopement book. Review of the progress notes documented the following: Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Nursing staff reported that resident was not in his room; Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Surrounding area outside the facility was initiated on foot and vehicle; Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Immediate search of the premises done, unable to locate the resident. Director of Nursing made aware. CODE GREEN announced to staff and complete search initiated; Dated 5/03/23 time stamped 18:15-No type specified: Late 105120 Page 8 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few entry-Administrator was notified; Dated 5/03/23 time stamped 19:18-No type specified: Late entry-Local police notified. Daughter and son was notified; Dated 5/03/23 time stamped 19:30-No type specified: Late entry-MD was notified; Dated 5/03/23 time stamped 19:35-No type specified: Late entry-Immediate complete head count initiated of all residents. No other elopements identified; Dated 5/03/23 time stamped 20:00-No type specified: Late entry-Head count by nurses 3 times a shift initiated; Dated 5/03/23 time stamped 20:00-No type specified: Late entry-Elopement books audited and in all nursing stations, reception area, back patio area; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Son visited facility and spoke with management. Emotional support provided; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Education on abuse, Neglect Policy and Procedure initiated; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Education to all staff on Elopement policy and Procedure initiated; Dated 5/03/23 time stamped 20:34-No type specified: Late entry-Situation Background Assessment Recommendation (SBAR) Summary for Providers: Dementia, Resident eloped; Dated 5/03/23 time stamped 20:45-No type specified: Late entry-Call placed to local agency [ ] report taken; Dated 5/03/23 time stamped 20:48-Alert Note: Resident awake, alert, oriented and ambulated without assistive device, under elopement watch. Around dinner time, was looking for resident when he was unable to be located. Search initiated by all staff, resident still not able to located. Responsible party and MD made aware of the incident. Local police [ ] also notified. Search continues for resident by all staff in the facility and off the facility with no positive result. Search is ongoing until resident is found; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Re-assessment of Elopement Risk Assessments initiated by nursing for all current resident; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Search of the surrounding area continue by staff on foot and by vehicles; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-All doors and exit doors checked by Maintenance staff; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-For residents identified as Elopement risk. Placed on hourly checks; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Staff assigned to call area Hospital emergency room in an attempt to locate the resident; Dated 5/03/23 time stamped 21:27-Health Status Note: Resident woke up and ate 100% breakfast, morning meds administered. He self ambulates, on close monitoring due constant exit seeking behavior; Dated 5/04/23 time stamped 08:00-No type specified: Late entry-Local Hospital emergency room contacted in effort to locate the resident; Dated 5/04/23 time stamped 11:00-No type specified: Late entry-Staff continue to call local hospital emergency room to locate the resident; Dated 5/04/23 time stamped 15:00-No type specified: Late entry-Local hospital emergency rooms contacted in effort to locate residents; Dated 5/05/23 time stamped 08:00-No type specified: Late entry-Local hospital emergency rooms contacted in effort to locate resident; Dated 5/05/23 time stamped 16:40-No type specified: Late entry-Police officer informed the administrator that resident was found [ ] local city; Dated 5/05/23 time stamped 16:47-Order Note: Resident's family was notified that the resident was found by police officer in [ ] local city. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for March 2023, April 2023 and May 2023 documented the resident was receiving the following medications: Valproic Acid Solution 250mg (milligrams)/5ml (milliliters) give 10ml PO (by mouth) BID (twice a day) a day for mood stabilizer; Quetiapine Fumarate 100mg tab (tablet) 1 tab PO BID for psychosis and Nitroglycerin 0.4mg tab 1 tab sublingually every 5 minutes PRN (as needed) for chest pain x (times) 3 doses (Started on 5/05/23). Medications were given as ordered by the medical doctor. The resident received medications on 5/03/23 at 9:00 AM but did not receive meds at 9:00 PM due to missing out of the facility. The resident had an order for a wander elopement alarm bracelet on 4/15/22 and was discontinued on 3/15/23. Review of the 105120 Page 9 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Elopement Risk Assessment/Evaluation dated 3/26/23 and 4/05/23 documented: The resident is at risk for elopement; Resident had verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors and Ambulates independently with or without the use of an assistive device. During a telephone interview with Resident's #1 daughter on 5/06/23 at 11:43 AM via telephone. She stated, The dispatchers found my father in [ ] local city. He is at the hospital now. My older brother is the POA (power of attorney) and has more that he can tell you. During a telephone interview with Resident's #1 son on 5/06/23 at 11:49 AM via telephone. He stated, My father was found in the city of [ ] near [ ] local city. He was found on yesterday, Friday and missing since Wednesday. He was missing for over 48 hours. I filed a missing person's report with the [ ] local city. My father was aware that he traveled far. He has a case of early dementia. I transported him to a [ ] local hospital and he is currently there. He was missing since Wednesday morning around 10:00 AM. Video footage showed my father leaving the facility on foot and my sister was contacted around 7:30 PM in the evening. On 5/08/23 at 11:25 AM, the Director of Nursing (DON)/Risk Manager/QAA (Quality Assessment and Assurance) stated, On 5/03/23, according to the nurse [Staff A, Licensed Practical Nurse (LPN)] at 5:45 PM she couldn't locate the resident in his room. They checked room to room on unit three with the help of other staff that was here. They also searched on Unit 1 and Unit 2 and outside on the premises. They couldn't find the patient. The patient was ambulatory, come to Unit 1 and go out to the patio and enjoyed participating in activities. At 6:00PM they confirmed the patient could not be found in the building. Immediately, they activated CODE GREEN our code for elopement. We searched again the area, informed the Administrator and informed all my interdisciplinary team to come back to the facility to look for the patient. At 7:18 PM, we called the police and the son and the daughter. Somewhere between 7:30-7:35PM, we did a complete head count of every resident in the building to verify if anyone was missing. Everyone was here, except the resident. At 8:13 PM, the son came to the facility and we gave him emotional support and told him what transpired. At 8:30 PM, the staff came back to the facility from searching and we started the education on elopement and on abuse and neglect. Around 8:45PM, we reported to [ ] local agency about the incident. We initiated the [ ] local Immediate Report by the Social Services Director. At 9:00 PM, we assigned a staff to call all emergency rooms in the area to find the patient. We checked all exit doors around that time. We continued searching for the resident. The nurses did reassessments for all residents at elopement risk. He was considered an elopement risk. He was able to remove the wander guard and the doctor discontinued the order for the wander elopement alarm. Some staff went about searching until 2:00AM in the morning and I continued searching until 5:00 AM in the morning. We identified four residents who were elopement risk but one had expired over the weekend. All elopements books were audited and updated. I gave instructions to do head count three times every shift (in the morning when they come in, 4 hours after that and before they leave for the day and then endorse it to the next staff). On 5/04/23 at 8:00 AM we started replacing the fence on the back patio because it was short and we replaced another gate on the back patio on yesterday. We now have the security guard who started on 5/05/23 to keep an eye on the back patio. We called the emergency rooms to locate the resident. We continued the education on elopement and abuse and neglect policy and we did an elopement drill. At 3:00 pm on 5/05/23 we continued to call the hospital emergency room. Around 8:00PM, the residents son came to talk to me and the Administrator. On 5/05/23, at 5:00 PM, the security guard company sent a guard to be stationed on the back patio. Security guard will be on the back patio for 24 hours, seven days a week. CNA will be assigned to be outside on the front patio 24 hours, seven days a week. At 4:40 PM, the police officer called the Administrator that the resident was found in [ ] local 105120 Page 10 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few city. He was knocking on peoples doors in the neighborhood where he was found. At 4:45 PM, I called the family, the son and told him the father was found by a certain police officer and he went to the [ ] local city to pick him up. Around 7:00PM, I called the son and he said the father is with me and we are on our way to the facility. He took him to eat something first and he said he wanted his father to go the local emergency room (ER) for evaluation. At 8:35PM, resident arrived in the company of his son. We readmitted the resident, reassessed him, offered fluids, food, ADLs and medications. We put him on 1 to 1. When he came back he was dirty, we tried to get him to take a shower but he refused. We asked the son to help us get him cleaned up. At 10:35 PM he was sent out to the [ ] local hospital ER for evaluation with the son by his bedside. Before this incident, the door to the back patio off Unit 2, the residents were able to push the door and go outside, there was no alarm. On 5/03/23, we started working on upgrading the door and the alarm system and it was not finished until mid-afternoon 5/03/23. The resident went outside the back door off of Unit 2. The back door off the Unit 2 now has an alarm and code. Only the staff has the code. We plan on changing the code every 2 months and we are checking doors everyday by the Maintenance Director. On 5/08/23 at 11:58 AM, the Administrator stated, There was an elopement, we did a search of the area. We called the police and let them know about a missing person, we let the family and the physician know. The police came and gave us the paperwork for the missing person. We started doing drill that night into the weekend and on elopement, abuse and neglect. On Friday 5/05/23 we got the call that he had been found. The police brought him back. He was then sent to the hospital for evaluation. Staff will be back to work on Wednesday, 5/10/23. I am not able to pull the footage because it overrides. I didn't get a chance to take still photos of the video. On 5/08/23 at 12:06 PM, the Social Service Director stated, On Wednesday about 5:45-5:50PM, the nursing staff reported that the resident was not in the building. The nursing staff as well as the managerial staff conducted an in-house search for the resident, we could not find him in the facility. Therefore, staff went out on foot, our cars to check the surrounding areas. We came back, we were not able to find the resident. We notified the police, doctor, family member. We continued to search for him. We called the hospitals in the area and no one found him. The police came and spoke with me, they met with the nursing staff assigned to the resident. I called [ ] local agency to make them aware and reported it. Friday afternoon about 4:40PM, the Administrator received a call from [ ] local police had found the resident. The resident returned to the facility around 7:00PM accompanied by his son. He was assessed by the nursing staff, the physician was made aware that the resident was found and the son and physician were in agreement for him to be sent to [ ] local hospital for further evaluation. On 5/08/23 at 3:33 PM, Staff C, Registered Nurse (RN) for the 3:00 PM to 11:00 PM shift stated, When I came in on 5/03/23 I did my rounds on Unit 1 and Unit 2. I was going up to Unit 3 and met the cna (certified nursing assistant) in the elevator and she told me she noticed he was missing. We started looking in bathrooms, rooms, dining room, trash rooms, med rooms. When we didn't see him, I pulled his chart he was not signed out by any family member. I came and told the DON and he called Code Green. We looked on all units, the patio, the DON informed the family and police. I was so frantic I got in my car and drove around looking for the resident. I drove around for 2 ½ hours looking for him and I didn't find him. When I came back, the police was here. On 5/05/23, I started the assessment and tried to clean him up. He was dirty and he had a smell. He didn't want us to clean him up, he went out of the room and said if you keep bothering me, I will go back downstairs to my son. The son came up and calmed him down, and he let us clean him. The son wanted him to go out to a [ ] local hospital for evaluation. We had put one to one in place for when he came back to the facility. No injuries were noted, he had very dry skin 105120 Page 11 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0607 and red were noted. Transportation came and the son left with the resident to the hospital. Level of Harm - Immediate jeopardy to resident health or safety On 5/09/23 at 8:23 AM, the Social Services Director stated, I was at the nurses' station with the nurse and I dialed the number for the son. We called the son, the voicemail was full and we could not leave a message. Then we proceeded to call the daughter who answered and the nurse told her about the incident. The resident's vision was impaired, he has cataracts. He did not have glasses. He had a Vision consult on 4/17/23 and the consult says he has cataracts. Residents Affected - Few On 5/09/23 at 8:31 AM, Staff D, Licensed Practical Nurse (LPN), Unit Manager 3 for the 7:00 AM to 3:00 PM shift stated, Like any other day, he ambulates. He likes to talk to other Spanish speaking residents. He goes downstairs to activities. Everyone in the building is aware that we need to keep an eye on him. There is nothing that is on a time schedule, the main thing is to keep him from the front door. He always talks about going to the bank. The week before he left and I told him he has money here. He went to the Business Office and they gave him $20.00 and he would carry it in his pocket. This was 8 days before he left. As far I know he didn't have any vision problems. As far I knew he was here in the facility all day. I saw him around 10:00 AM. I had already left for the day and they notified me he was missing because he didn't show up for dinner. I got in my car and came back immediately. I drove around the neighborhood looking for him. He went out the back door on Unit 2, took a chair, took off his shoes and used his toes to get in the grooves of the fence and climbed over. On 5/09/23 at 8:39 AM via telephone Staff A, LPN for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, I took his vital signs and gave him medications around 9:30 AM. He ate his breakfast. He walks up and down and goes downstairs on the patio. I didn't have to give him his medications until 1:00pm. He received medications at 9:00 am and 5:00pm. The cna put his lunch tray in his room and she did not go back to see if he ate or not. She removed the lunch tray when it was time to give him his dinner tray. That's when she realized that he was missing. She came to me and said she didn't see him. I asked her did he eat and I saw his lunch tray. I said he didn't he eat and she said no. We went room to room. I called the supervisor and told him. I went in my car and rode all around and he was nowhere to be found. I can say the incident was negligence. I was praying that he would be found alive and God answered my prayers. On 5/09/23 at 8:47 AM via telephone Staff B, Certified Nursing Assistant (CNA) for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, When I came on Wednesday to work I saw all my patients. I gave him his breakfast and he eat and I took up his tray. I put his lunch tray in the room because he was downstairs. He would come and eat the food. I went to the other patients and was taking care of them. Sometimes he would eat in the dining room upstairs. I have 11 patients to care of and he didn't listen. I tell him not to go downstairs, he don't listen to you. The camera showed he left at 10:30 AM. I was working a double shift on that day. When I put the dinner tray, I saw the lunch tray there and I said where is he. I don't see him. I went to the nurse and we started checking for him. On 5/09/23 at 9:03 AM, the Human Resources Manager stated, We couldn't see much because of the site where he jumped. He pulled a chair, to the fence and jumped over the fence. The incident occurred according to the video around 10:37 AM. It was so quick. There was much not evidence on the video. We didn't get a clear picture of him because the camera didn't get the side of the patio. On 5/10/23 at 10:06 AM, the Business Office Manager stated, He had a personal funds account and his check started coming here about a month ago. He came to me on 4/25/23 and he received $20.00. 105120 Page 12 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0607 The facility's immediate jeopardy removal plan included: Level of Harm - Immediate jeopardy to resident health or safety The staff were In-serviced/trained on 5/03/23 for 3PM-11PM shift, 11PM-7AM shift for nurses and certified nursing assistants (CNA) and 5/04/23 for 7AM-3PM shift, 3PM-11PM shift and 11PM-7AM shift for nurses and CNAs regarding: Wandering precautions and wander/elopement alarm device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. On 5/4-7/23 on all shifts for nurses, cnas and all staff were in-serviced/trained on an elopement drill and abuse and neglect. A 24-hour security guard was brought in to monitor the back exits. The facility installed an alarm system that is audible at the nursing station and care areas were added to the exit door on Unit 2, to alert the staff of any residents trying to exit the door. Maintenance staff or their qualified designees, conduct daily door audits to ensure all door are in proper working order, including checking that the alarm is audible at the nursing station and care areas. A 6-foot fence was installed to the back end of the smoking area, to ensure that residents remain in the smoking area. The gate will be monitored by the patio area's CNA or designated staff member. A security guard has been assigned to watch the north-west gated area during the ongoing updates to the facility's security systems. Residents Affected - Few An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code green, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on 5/03/23 for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor the north-west gated area exits. Prompt re-training was initiated on 5/04/23 for all shifts regarding Abuse Reporting, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1, Close Monitoring and Code Green. The immediate jeopardy removal plan was verified as completed from May 8 - 10, 2023 by reviewing the above documentation; observing the back patio; observing the coded, audible alarm exit door on Unit 2; interviewing the security guard on the back patio; interviewing (16) staff members to verify they received elopement inservices, participated in elopement drills, inservice on checking wander guards, abuse and neglect inservices. The verification included RN's, LPN's, and CNA's from the 7-3, 3-11 and 11-7 shifts. Reviewed inservices and sign in sheets for: Date - 5/03/23; Title of the In-Service: Elopement Drill; Audience: All staff Date - 5/04/23; Title of the In-Service: Elopement; Elopement Drill; Audience: All staff Date - 5/04/23; Title of the In-Service: Neglect; Audience: All staff Date - 5/05/23; Title of the In-Service: Neglect; Audience: All staff Date - 5/05/23; Title of the In-Service: Elopement Drill; Audience: All staff Date - 5/6-7/23; Title of the In-Service: Neglect; Audience: All staff 105120 Page 13 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0607 Date - 5/6-7/23; Title of the In-Service: Elopement Drill; Audience: All staff Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 105120 Page 14 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) assessment for one (Resident number 2) out of three residents reviewed for residents with wander/elopement alarm assessments. Resident #2 was coded as not having a wander/elopement alarm. There were three residents with wander elopement alarms. There were 107 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Record review of the Conducting an Accurate Resident Assessment Policy and Procedure (implemented 11/28/2017, reviewed 10/26/2022) documented the following: Policy Statement: This policy is to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths and areas of decline. Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (comprehensive, quarterly, significant change in status). Policy Explanation and Compliance Guidelines: 2) Qualified staff who are knowledgeable about the resident will conduct an accurate assessment addressing each resident's status, needs, strengths and areas of decline. The assessment will be documented in the medical record; 3) The appropriate qualified health professional will correctly document the resident's medical, functional and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities and psychosocial status and 10) The assessment must represent an accurate picture of the resident's status during the observation period of the MDS (Minimum Data Set). Initial observation of Resident #2 on 5/08/23 at 11:03 AM revealed the resident sitting in a chair in her room, watching television and wearing a wander/elopement alarm on her right arm. Second observation of Resident #2 on 5/09/23 at 12:18 PM revealed the resident sitting in a chair in her room, watching television, eating lunch and wearing wander/elopement alarm on her right arm. Third observation of Resident #2 on 5/10/23 at 7:56 AM revealed the resident sitting up in bed, watching television, eating breakfast and wearing a wander/elopement alarm on her right arm. Review of the Demographic Face Sheet for Resident #2 documented the resident was admitted on [DATE] with diagnoses of dementia, osteoarthritis, age-related macular degeneration bilateral, insomnia, major depressive disorder, atrial fibrillation, hypertension and anxiety disorder. Review of the Quarterly MDS, dated [DATE] for Resident #2 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 11 out of 15 indicating mild cognitive impairment and the resident was able to make her needs known. The resident's vision was impaired, used no corrective lenses, required independent to supervision with setup only to extensive assistance with one person physical assist for ADLs (Activities of Daily Living) and no wander/elopement alarms were used. The resident wore a wander/elopement alarm on her right arm. Review of the Physician's Order Sheet (POS) dated April 2023, May 2023 for Resident #2 documented 105120 Page 15 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the wander/elopement alarm to be monitored every shift for placement (Start date 6/01/21); to check the wander/elopement alarm daily for proper functioning (Start date 6/01/21) and the wander/elopement alarm to alert staff of attempt to leave facility unsupervised (Revision date 6/01/21). Review of the Treatment Administration Record (TAR) dated April 2023, May 2023 for Resident #2 documented the wander/elopement alarm was checked daily. Review of the Behavior Problem Care Plan for Resident #2 (written 6/01/21) documented the resident had a behavior problem she has been exhibiting periods of increased restlessness and wanted her wander/elopement alarm removed; Goal: Resident will have fewer episodes of increase restlessness throughout the review date. Also, resident will be checked for wander/elopement alarm daily and Intervention: Assess for wander/elopement alarm daily. Review of the Residents at Risk with Elopement and with Wander/Elopement Alarm log dated 5/08/23 documented the resident was listed on the log. Review of the Elopement Risk Assessment/Evaluation for Resident #2 dated 3/06/23 and 5/04/23 documented: The resident was at risk for elopement; Resident had verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors; Ambulates independently with or without the use of an assistive device. Interview with the Director of Nursing (DON) on 5/08/23 at 9:37 AM. He stated, The resident is considered an elopement risk and wears a wander/elopement alarm. Interview and record review with Staff E, Licensed Practical Nurse (LPN) MDS Coordinator on 5/10/23 at 12:53 PM. She stated, The MDS Quarterly dated 3/06/2023 says no wander/elopement alarms used. I did the assessment for the resident. She has an order for the wander/elopement alarm which started on 6/01/21. She has a care plan for behaviors which includes the wander alarm and elopement. The MDS assessment is not accurate. Interview with Staff F, Registered Nurse (RN) on 5/10/23 at 2:37 PM. She stated, The resident wears the wander/elopement alarm on the right arm. She ambulates around the unit but not downstairs. The functioning of the wander/elopement alarm is checked daily and for placement checked every shift. It is documented on the TAR. The wander guard will go off, if they go near an exit door. Interview with Staff G, Certified Nursing Assistant (CNA) 5/10/23 2:51 PM. She stated, The resident wears the bracelet monitor on her right arm. She walks around the floor but never goes downstairs. 105120 Page 16 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide adequate supervision and a secured environment for one (Resident #1) out of four sampled residents with exit seeking behaviors. This deficient practice enabled Resident #1 to exit the facility at 10:32 AM on 5/03/23, undetected. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate and effective alert monitoring system was in place allowed the resident to elope undetected by staff on 5/03/23 at 10:32 AM. The resident was not located until 6:10 PM on 5/05/23 wandering in a neighborhood 17.1 miles from the facility by law enforcement who reported Resident #1's location to the resident's son. There were 107 residents residing in the facility at the time of the survey. The scope and severity of F689 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of 5/10/23. The scope and severity was lowered as a result of the facility's removal of immediate jeopardy actions implemented as of 5/10/23. The facility continued to have noncompliance at a lower scope and severity. These corrective actions were verified by the survey team through observation, record review and interview on 5/8-10/23. Refer to F 600, F 607 and F 835. The findings included: Record review of the facility's policy titled, Elopement and Wandering Residents revised February 2022 documented: Policy Statement: Residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1) Wandering is random or repetitive locomotion that may be goal-directed (the person appears to be searching for something such as an exit) or non-goal directed or aimless; 2) Elopement occurs when a resident leaves the premises or a safe area without authorization; 5) The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions; 6) Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: d) Adequate supervision will be provided to help prevent accidents or elopements and 7) Procedure for Locating Missing Resident a) Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (internal alert code). Review of the facility's policy titled, Accidents and Supervision revised November 2022 documented: Policy Statement: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1) Identifying hazards and risks, 2) Evaluating and analyzing hazards and risks, 3) Implementing interventions to reduce hazards and risks and 4) Monitoring effectiveness and modifying interventions; Policy Explanation and Compliance Guidelines: 5) Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. 105120 Page 17 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with diagnoses of dementia, psychosis, mood affective disorder, muscle weakness and unsteadiness on feet. Review of the Annual MDS (Minimum Data Set), dated 4/03/23 for Resident #1 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 12 out of 15 indicating mild cognitive impairment and the resident was able to make his needs known. The resident's vision was impaired, used no corrective lenses, required supervision to limited assistance with setup only to one person with physical assist for ADLs (Activities of Daily Living) and no wander/elopement alarms were used. He was able to make needs known and can follow simple commands. Review of the Elopement Risk Assessment/Evaluation dated 3/26/23 and 4/05/23 documented: The resident is at risk for elopement; Resident had verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors and Ambulates independently with or without the use of an assistive device. Review of Resident's #1 Elopement care plan dated 4/15/22 documented the resident is an elopement risk related to impaired safety awareness. Resident is refusing to wear his wander guard; Goal: Resident will not leave facility unattended and he will wear the wander guard throughout the review date; Apply wander guard; Elopement assessment to be completed; Take photo and place in the elopement book. Review of the progress notes documented the following: Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Nursing staff reported that resident was not in his room; Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Surrounding area outside the facility was initiated on foot and vehicle; Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Immediate search of the premises done, unable to locate the resident. Director of Nursing made aware. CODE GREEN announced to staff and complete search initiated; Dated 5/03/23 time stamped 18:15-No type specified: Late entry-Administrator was notified; Dated 5/03/23 time stamped 19:18-No type specified: Late entry-Local police notified. Daughter and son was notified; Dated 5/03/23 time stamped 19:30-No type specified: Late entry-MD was notified; Dated 5/03/23 time stamped 19:35-No type specified: Late entry-Immediate complete head count initiated of all residents. No other elopements identified; Dated 5/03/23 time stamped 20:00-No type specified: Late entry-Head count by nurses 3 times a shift initiated; Dated 5/03/23 time stamped 20:00-No type specified: Late entry-Elopement books audited and in all nursing stations, reception area, back patio area; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Son visited facility and spoke with management. Emotional support provided; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Education on abuse, Neglect Policy and Procedure initiated; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Education to all staff on Elopement policy and Procedure initiated; Dated 5/03/23 time stamped 20:34-No type specified: Late entry-Situation Background Assessment Recommendation (SBAR) Summary for Providers: Dementia, Resident eloped; Dated 5/03/23 time stamped 20:45-No type specified: Late entry-Call placed to local agency [ ] report taken; Dated 5/03/23 time stamped 20:48-Alert Note: Resident awake, alert, oriented and ambulated without assistive device, under elopement watch. Around dinner time, was looking for resident when he was unable to be located. Search initiated by all staff, resident still not able to located. Responsible party and MD made aware of the incident. Local police [ ] also notified. Search continues for resident by all staff in the facility and off the facility with no positive result. Search is ongoing until resident is found; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Re-assessment of Elopement Risk Assessments initiated by nursing for all current resident; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Search of the surrounding area continue by staff on 105120 Page 18 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few foot and by vehicles; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-All doors and exit doors checked by Maintenance staff; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-For residents identified as Elopement risk. Placed on hourly checks; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Staff assigned to call area Hospital emergency room in an attempt to locate the resident; Dated 5/03/23 time stamped 21:27-Health Status Note: Resident woke up and ate 100% breakfast, morning meds administered. He self ambulates, on close monitoring due constant exit seeking behavior; Dated 5/04/23 time stamped 08:00-No type specified: Late entry-Local Hospital emergency room contacted in effort to locate the resident; Dated 5/04/23 time stamped 11:00-No type specified: Late entry-Staff continue to call local hospital emergency room to locate the resident; Dated 5/04/23 time stamped 15:00-No type specified: Late entry-Local hospital emergency rooms contacted in effort to locate residents; Dated 5/05/23 time stamped 08:00-No type specified: Late entry-Local hospital emergency rooms contacted in effort to locate resident; Dated 5/05/23 time stamped 16:40-No type specified: Late entry-Police officer informed the administrator that resident was found [ ] local city; Dated 5/05/23 time stamped 16:47-Order Note: Resident's family was notified that the resident was found by police officer in [ ] local city. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for March 2023, April 2023 and May 2023 documented the resident was receiving the following medications: Valproic Acid Solution 250mg (milligrams)/5ml (milliliters) give 10ml PO (by mouth) BID (twice a day) a day for mood stabilizer; Quetiapine Fumarate 100mg tab (tablet) 1 tab PO BID for psychosis and Nitroglycerin 0.4mg tab 1 tab sublingually every 5 minutes PRN (as needed) for chest pain x (times) 3 doses (Started on 5/05/23). Medications were given as ordered by the medical doctor. The resident received medications on 5/03/23 at 9:00 AM but did not receive meds at 9:00 PM due to missing out of the facility. The resident had an order for a wander elopement alarm bracelet on 4/15/22 and was discontinued on 3/15/23. Based on observational tour of the facility's parameter increased risk factors included the fact that, the facility is located in an area that has high traffic volume, busy intersections and is located near a major highway and train tracks. Both locations where the facility is located and the location where the resident was found, are high traffic areas with busy two laned roads and four laned cross streets. The National Weather Service climate Data for the Miami area May 3, 2023 to May 5, 2023 ranged at record breaking temperatures of 82 degrees Fahrenheit (F) to 92 degrees F. During a telephone interview with Resident's #1 daughter on 5/06/23 at 11:43 AM via telephone. She stated, The dispatchers found my father in [ ] local city. He is at the hospital now. My older brother is the POA (power of attorney) and has more that he can tell you. During a telephone interview with Resident's #1 son on 5/06/23 at 11:49 AM via telephone. He stated, My father was found in the city of [ ] near [ ] local city. He was found on yesterday, Friday and missing since Wednesday. He was missing for over 48 hours. I filed a missing person's report with the [ ] local city. My father was aware that he traveled far. He has a case of early dementia. I transported him to a [ ] local hospital and he is currently there. He was missing since Wednesday morning around 10:00 AM. Video footage showed my father leaving the facility on foot and my sister was contacted around 7:30 PM in the evening. On 5/08/23 at 11:25 AM, the Director of Nursing (DON)/Risk Manager/QAA (Quality Assessment and Assurance) stated, On 5/03/23, according to the nurse [Staff A, Licensed Practical Nurse (LPN)] at 5:45 105120 Page 19 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few PM she couldn't locate the resident in his room. They checked room to room on unit three with the help of other staff that was here. They also searched on Unit 1 and Unit 2 and outside on the premises. They couldn't find the patient. The patient was ambulatory, come to Unit 1 and go out to the patio and enjoyed participating in activities. At 6:00PM they confirmed the patient could not be found in the building. Immediately, they activated CODE GREEN our code for elopement. We searched again the area, informed the Administrator and informed all my interdisciplinary team to come back to the facility to look for the patient. At 7:18 PM, we called the police and the son and the daughter. Somewhere between 7:30-7:35PM, we did a complete head count of every resident in the building to verify if anyone was missing. Everyone was here, except the resident. At 8:13 PM, the son came to the facility and we gave him emotional support and told him what transpired. At 8:30 PM, the staff came back to the facility from searching and we started the education on elopement and on abuse and neglect. Around 8:45PM, we reported to [ ] local agency about the incident. We initiated the [ ] local Immediate Report by the Social Services Director. At 9:00 PM, we assigned a staff to call all emergency rooms in the area to find the patient. We checked all exit doors around that time. We continued searching for the resident. The nurses did reassessments for all residents at elopement risk. He was considered an elopement risk. He was able to remove the wander guard and the doctor discontinued the order for the wander elopement alarm. Some staff went about searching until 2:00AM in the morning and I continued searching until 5:00 AM in the morning. We identified four residents who were elopement risk but one had expired over the weekend. All elopements books were audited and updated. I gave instructions to do head count three times every shift (in the morning when they come in, 4 hours after that and before they leave for the day and then endorse it to the next staff). On 5/04/23 at 8:00 AM we started replacing the fence on the back patio because it was short and we replaced another gate on the back patio on yesterday. We now have the security guard who started on 5/05/23 to keep an eye on the back patio. We called the emergency rooms to locate the resident. We continued the education on elopement and abuse and neglect policy and we did an elopement drill. At 3:00 pm on 5/05/23 we continued to call the hospital emergency room. Around 8:00PM, the residents son came to talk to me and the Administrator. On 5/05/23, at 5:00 PM, the security guard company sent a guard to be stationed on the back patio. Security guard will be on the back patio for 24 hours, seven days a week. CNA will be assigned to be outside on the front patio 24 hours, seven days a week. At 4:40 PM, the police officer called the Administrator that the resident was found in [ ] local city. He was knocking on peoples doors in the neighborhood where he was found. At 4:45 PM, I called the family, the son and told him the father was found by a certain police officer and he went to the [ ] local city to pick him up. Around 7:00PM, I called the son and he said the father is with me and we are on our way to the facility. He took him to eat something first and he said he wanted his father to go the local emergency room (ER) for evaluation. At 8:35PM, resident arrived in the company of his son. We readmitted the resident, reassessed him, offered fluids, food, ADLs and medications. We put him on 1 to 1. When he came back he was dirty, we tried to get him to take a shower but he refused. We asked the son to help us get him cleaned up. At 10:35 PM he was sent out to the [ ] local hospital ER for evaluation with the son by his bedside. Before this incident, the door to the back patio off Unit 2, the residents were able to push the door and go outside, there was no alarm. On 5/03/23, we started working on upgrading the door and the alarm system and it was not finished until mid-afternoon 5/04/23. The resident went outside the back door off of Unit 2. The back door off the Unit 2 now has an alarm and code. Only the staff has the code. We plan on changing the code every 2 months and we are checking doors everyday by the Maintenance Director. On 5/08/23 at 11:58 AM, the Administrator stated, There 105120 Page 20 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0689 Level of Harm - Immediate jeopardy to resident health or safety was an elopement, we did a search of the area. We called the police and let them know about a missing person, we let the family and the physician know. The police came and gave us the paperwork for the missing person. We started doing drill that night into the weekend and on elopement, abuse and neglect. On Friday 5/05/23 we got the call that he had been found. The police brought him back. He was then sent to the hospital for evaluation. Staff will be back to work on Wednesday, 5/10/23. I am not able to pull the footage because it overrides. I didn't get a chance to take still photos of the video. Residents Affected - Few On 5/08/23 at 12:06 PM, the Social Service Director stated, On Wednesday about 5:45-5:50PM, the nursing staff reported that the resident was not in the building. The nursing staff as well as the managerial staff conducted an in-house search for the resident, we could not find him in the facility. Therefore, staff went out on foot, our cars to check the surrounding areas. We came back, we were not able to find the resident. We notified the police, doctor, family member. We continued to search for him. We called the hospitals in the area and no one found him. The police came and spoke with me, they met with the nursing staff assigned to the resident. I called [ ] local agency to make them aware and reported it. Friday afternoon about 4:40PM, the Administrator received a call from [ ] local police had found the resident. The resident returned to the facility around 7:00PM accompanied by his son. He was assessed by the nursing staff, the physician was made aware that the resident was found and the son and physician were in agreement for him to be sent to [ ] local hospital for further evaluation. On 5/08/23 at 3:33 PM, Staff C, Registered Nurse (RN) for the 3:00 PM to 11:00 PM shift stated, When I came in on 5/03/23 I did my rounds on Unit 1 and Unit 2. I was going up to Unit 3 and met the cna (certified nursing assistant) in the elevator and she told me she noticed he was missing. We started looking in bathrooms, rooms, dining room, trash rooms, med rooms. When we didn't see him, I pulled his chart he was not signed out by any family member. I came and told the DON and he called Code Green. We looked on all units, the patio, the DON informed the family and police. I was so frantic I got in my car and drove around looking for the resident. I drove around for 2 ½ hours looking for him and I didn't find him. When I came back, the police was here. On 5/05/23, I started the assessment and tried to clean him up. He was dirty and he had a smell. He didn't want us to clean him up, he went out of the room and said if you keep bothering me, I will go back downstairs to my son. The son came up and calmed him down, and he let us clean him. The son wanted him to go out to a [ ] local hospital for evaluation. We had put one to one in place for when he came back to the facility. No injuries were noted, he had very dry skin and red were noted. Transportation came and the son left with the resident to the hospital. On 5/09/23 at 8:23 AM, the Social Services Director stated, I was at the nurses' station with the nurse and I dialed the number for the son. We called the son, the voicemail was full and we could not leave a message. Then we proceeded to call the daughter who answered and the nurse told her about the incident. The resident's vision was impaired, he has cataracts. He did not have glasses. He had a Vision consult on 4/17/23 and the consult says he has cataracts. On 5/09/23 at 8:31 AM, Staff D Licensed Practical Nurse (LPN), Unit Manager 3 for the 7:00 AM to 3:00 PM shift stated, Like any other day, he ambulates. He likes to talk to other Spanish speaking residents. He goes downstairs to activities. Everyone in the building is aware that we need to keep an eye on him. There is nothing that is on a time schedule, the main thing is to keep him from the front door. He always talks about going to the bank. The week before he left and I told him he has money here. He went to the Business Office and they gave him $20.00 and he would carry it in his pocket. This was 8 days before he left. As far I know he didn't have any vision problems. As far I knew he 105120 Page 21 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few was here in the facility all day. I saw him around 10:00 AM. I had already left for the day and they notified me he was missing because he didn't show up for dinner. I got in my car and came back immediately. I drove around the neighborhood looking for him. He went out the back door on Unit 2, took a chair, took off his shoes and used his toes to get in the grooves of the fence and climbed over. On 5/09/23 at 8:39 AM via telephone Staff A, LPN for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, I took his vital signs and gave him medications around 9:30 AM. He ate his breakfast. He walks up and down and goes downstairs on the patio. I didn't have to give him his medications until 1:00pm. He received medications at 9:00 am and 5:00pm. The cna put his lunch tray in his room and she did not go back to see if he ate or not. She removed the lunch tray when it was time to give him his dinner tray. That's when she realized that he was missing. She came to me and said she didn't see him. I asked her did he eat and I saw his lunch tray. I said he didn't he eat and she said no. We went room to room. I called the supervisor and told him. I went in my car and rode all around and he was nowhere to be found. I can say the incident was negligence. I was praying that he would be found alive and God answered my prayers. On 5/09/23 at 8:47 AM via telephone Staff B, Certified Nursing Assistant (CNA) for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, When I came on Wednesday to work I saw all my patients. I gave him his breakfast and he eat and I took up his tray. I put his lunch tray in the room because he was downstairs. He would come and eat the food. I went to the other patients and was taking care of them. Sometimes he would eat in the dining room upstairs. I have 11 patients to care of and he didn't listen. I tell him not to go downstairs, he don't listen to you. The camera showed he left at 10:30 AM. I was working a double shift on that day. When I put the dinner tray, I saw the lunch tray there and I said where is he. I don't see him. I went to the nurse and we started checking for him. On 5/09/23 at 9:03 AM, the Human Resources Manager stated, We couldn't see much because of the site where he jumped. He pulled a chair, to the fence and jumped over the fence. The incident occurred according to the video around 10:37 AM. It was so quick. There was much not evidence on the video. We didn't get a clear picture of him because the camera didn't get the side of the patio. On 5/10/23 at 10:06 AM, the Business Office Manager stated, He had a personal funds account and his check started coming here about a month ago. He came to me on 4/25/23 and he received $20.00. The facility's immediate jeopardy removal plan included: The staff were In-serviced/trained on 5/03/23 for 3PM-11PM shift, 11PM-7AM shift for nurses and certified nursing assistants (CNA) and 5/04/23 for 7AM-3PM shift, 3PM-11PM shift and 11PM-7AM shift for nurses and CNAs regarding: Wandering precautions and wander/elopement alarm device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. On 5/4-7/23 on all shifts for nurses, cnas and all staff were in-serviced/trained on an elopement drill and abuse and neglect. A 24-hour security guard was brought in to monitor the back exits. The facility installed an alarm system that is audible at the nursing station and care areas were added to the exit door on Unit 2, to alert the staff of any residents trying to exit the door. Maintenance staff or their qualified designees, conduct daily door audits to ensure all door are in proper working order, including checking that the alarm is audible at the nursing station and care areas. A 6-foot fence was installed to the back end of the smoking area, to ensure that residents remain in the smoking area. The gate will be monitored by the patio area's CNA or designated staff member. A security guard has been assigned to watch the north-west gated area during the ongoing updates to the facility's security systems. 105120 Page 22 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code green, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on 5/03/23 for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor the north-west gated area exits. Prompt re-training was initiated on 5/04/23 for all shifts regarding Abuse Reporting, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1, Close Monitoring and Code Green. The immediate jeopardy removal plan was verified as completed from May 8 - 10, 2023 by reviewing the above documentation; observing the back patio; observing the coded, audible alarm exit door on Unit 2; interviewing the security guard on the back patio; interviewing (16) staff members to verify they received elopement inservices, participated in elopement drills, inservice on checking wander guards, abuse and neglect inservices. The verification included RN's, LPN's, and CNA's from the 7-3, 3-11 and 11-7 shifts. Reviewed inservices and sign in sheets for: Date - 5/03/23; Title of the In-Service: Elopement Drill; Audience: All staff Date - 5/04/23; Title of the In-Service: Elopement; Elopement Drill; Audience: All staff Date - 5/04/23; Title of the In-Service: Neglect; Audience: All staff Date - 5/05/23; Title of the In-Service: Neglect; Audience: All staff Date - 5/05/23; Title of the In-Service: Elopement Drill; Audience: All staff Date - 5/6-7/23; Title of the In-Service: Neglect; Audience: All staff Date - 5/6-7/23; Title of the In-Service: Elopement Drill; Audience: All staff 105120 Page 23 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility's administration failed to implement, provide and ensure an effective and efficient preventative measures were in place to prevent the neglect and elopement of one resident (Resident #1) out of four sampled residents who displayed exit seeking behaviors. As evidenced by inadequate safety measures that included failure to ensure exit door alarm was audible in all areas of the facility in the event of an emergency and failure by staff to implement assigned level of supervision for resident #1 who was a high risk for elopement. These deficient practices enabled resident #1 to exit the facility undetected at 10:32 AM through an emergency exit door on 5/03/23 placing the resident at risk for harm and/or injury. There were 107 residents residing in the facility at the time of the survey. Residents Affected - Few The scope and severity of F835 was lowered to a (D) for No actual harm with a potential for more than minimal harm that is not immediate jeopardy as of 5/10/23. The scope and severity was lowered as a result of the facility's removal of immediate jeopardy actions implemented as of 5/10/23. The facility continued to have noncompliance at a lower scope and severity. These corrective actions were verified by the survey team through observation, record review and interview on 5/8-10/23. Refer to F 600, F 607 and F 689. The findings included: Record review of the facility's policy titled, Freedom from Abuse, Neglect and Exploitation protocol implementation date was on 11/2017, 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 and corporal punishment 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, Elopement and Wandering Residents revised February 2022 documented: Policy Statement: Residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Policy Explanation and Compliance Guidelines: 1) Wandering is random or repetitive locomotion that may be goal-directed (the person appears to be searching for something such as an exit) or non-goal directed or aimless; 2) Elopement occurs when a resident leaves the premises or a safe area without authorization; 5) The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness and modifying interventions; 6) Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: d) Adequate supervision will be provided to help prevent accidents or elopements and 7) Procedure for Locating Missing Resident a) Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (internal alert code). 105120 Page 24 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the Job Description for the Nursing Home Administrator documented: The Administrator is responsible for developing, managing and supervising the overall functions of the facility in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Director of Nursing documented: The Director of Nursing is responsible for planning, organizing, developing and directing the day to day functions of the nursing department in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Nursing Supervisor documented: The Nursing Supervisor is responsible for supervising the day to day nursing activities in accordance with current Federal, state and local standards and established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Registered Nurse documented: The primary purpose of your job description is to provide direct nursing care the residents and to supervise the day to day nursing activities performed by nursing assistants. Such supervision must be in accordance with current federal, state and local standards, guidelines and regulations that govern our facility and as may be required by the Director of Nursing services to ensure that the highest degree of quality care is maintained at all times. Review of the Job Description for the Licensed Practical Nurse documented: The Licensed Practical Nurse is responsible for providing professional care in accordance with established nursing policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Review of the Job Description for the Certified Nursing Assistant documented: The Certified Nursing Assistant is responsible for providing professional care in accordance with established certified nursing assistant policies and procedures. He/she is also responsible for providing a positive, caring and homelike environment for the residents. Based on observational tour of the facility's parameter increased risk factors included the fact that, the Facility is in an area that has high traffic volume, busy intersections and is located near a major highway and train tracks. Review of the Demographic Face Sheet for Resident #1 documented the resident was initially admitted on [DATE] with diagnoses of dementia, psychosis, mood affective disorder, muscle weakness and unsteadiness on feet. Review of Resident's #1 Elopement care plan dated 4/15/22 documented the resident is an elopement risk related to impaired safety awareness. Resident is refusing to wear his wander guard; Goal: Resident will not leave facility unattended and he will wear the wander guard throughout the review date; Apply wander guard; Elopement assessment to be completed; Take photo and place in the elopement book. Review of the progress notes documented the following: Dated 5/03/23 time stamped 18:00-No type 105120 Page 25 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few specified: Late entry-Nursing staff reported that resident was not in his room; Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Surrounding area outside the facility was initiated on foot and vehicle; Dated 5/03/23 time stamped 18:00-No type specified: Late entry-Immediate search of the premises done, unable to locate the resident. Director of Nursing made aware. CODE GREEN announced to staff and complete search initiated; Dated 5/03/23 time stamped 18:15-No type specified: Late entry-Administrator was notified; Dated 5/03/23 time stamped 19:18-No type specified: Late entry-Local police notified. Daughter and son was notified; Dated 5/03/23 time stamped 19:30-No type specified: Late entry-MD was notified; Dated 5/03/23 time stamped 19:35-No type specified: Late entry-Immediate complete head count initiated of all residents. No other elopements identified; Dated 5/03/23 time stamped 20:00-No type specified: Late entry-Head count by nurses 3 times a shift initiated; Dated 5/03/23 time stamped 20:00-No type specified: Late entry-Elopement books audited and in all nursing stations, reception area, back patio area; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Son visited facility and spoke with management. Emotional support provided; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Education on abuse, Neglect Policy and Procedure initiated; Dated 5/03/23 time stamped 20:30-No type specified: Late entry-Education to all staff on Elopement policy and Procedure initiated; Dated 5/03/23 time stamped 20:34-No type specified: Late entry-Situation Background Assessment Recommendation (SBAR) Summary for Providers: Dementia, Resident eloped; Dated 5/03/23 time stamped 20:45-No type specified: Late entry-Call placed to local agency [ ] report taken; Dated 5/03/23 time stamped 20:48-Alert Note: Resident awake, alert, oriented and ambulated without assistive device, under elopement watch. Around dinner time, was looking for resident when he was unable to be located. Search initiated by all staff, resident still not able to located. Responsible party and MD made aware of the incident. Local police [ ] also notified. Search continues for resident by all staff in the facility and off the facility with no positive result. Search is ongoing until resident is found; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Re-assessment of Elopement Risk Assessments initiated by nursing for all current resident; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Search of the surrounding area continue by staff on foot and by vehicles; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-All doors and exit doors checked by Maintenance staff; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-For residents identified as Elopement risk. Placed on hourly checks; Dated 5/03/23 time stamped 21:00-No type specified: Late entry-Staff assigned to call area Hospital emergency room in an attempt to locate the resident; Dated 5/03/23 time stamped 21:27-Health Status Note: Resident woke up and ate 100% breakfast, morning meds administered. He self ambulates, on close monitoring due constant exit seeking behavior; Dated 5/04/23 time stamped 08:00-No type specified: Late entry-Local Hospital emergency room contacted in effort to locate the resident; Dated 5/04/23 time stamped 11:00-No type specified: Late entry-Staff continue to call local hospital emergency room to locate the resident; Dated 5/04/23 time stamped 15:00-No type specified: Late entry-Local hospital emergency rooms contacted in effort to locate residents; Dated 5/05/23 time stamped 08:00-No type specified: Late entry-Local hospital emergency rooms contacted in effort to locate resident; Dated 5/05/23 time stamped 16:40-No type specified: Late entry-Police officer informed the administrator that resident was found [ ] local city; Dated 5/05/23 time stamped 16:47-Order Note: Resident's family was notified that the resident was found by police officer in [ ] local city. Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) for March 2023, April 2023 and May 2023 documented the resident was receiving the following medications: Valproic Acid Solution 250mg (milligrams)/5ml (milliliters) give 10ml PO (by mouth) BID (twice a day) a day for mood stabilizer; Quetiapine 105120 Page 26 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Fumarate 100mg tab (tablet) 1 tab PO BID for psychosis and Nitroglycerin 0.4mg tab 1 tab sublingually every 5 minutes PRN (as needed) for chest pain x (times) 3 doses (Started on 5/05/23). Medications were given as ordered by the medical doctor. The resident received medications on 5/03/23 at 9:00 AM but did not receive meds at 9:00 PM due to missing out of the facility. The resident had an order for a wander elopement alarm bracelet on 4/15/22 and was discontinued on 3/15/23. Review of the Elopement Risk Assessment/Evaluation dated 3/26/23 and 4/05/23 documented: The resident is at risk for elopement; Resident had verbalized the desire to go home, packed their belongings, stood by exit doors, attempted to open exit doors and Ambulates independently with or without the use of an assistive device. During a telephone interview with Resident's #1 daughter on 5/06/23 at 11:43 AM via telephone. She stated, The dispatchers found my father in [ ] local city. He is at the hospital now. My older brother is the POA (power of attorney) and has more that he can tell you. During a telephone interview with Resident's #1 son on 5/06/23 at 11:49 AM via telephone. He stated, My father was found in the city of [ ] near [ ] local city. He was found on yesterday, Friday and missing since Wednesday. He was missing for over 48 hours. I filed a missing person's report with the [ ] local city. My father was aware that he traveled far. He has a case of early dementia. I transported him to a [ ] local hospital and he is currently there. He was missing since Wednesday morning around 10:00 AM. Video footage showed my father leaving the facility on foot and my sister was contacted around 7:30 PM in the evening. On 5/08/23 at 11:25 AM, the Director of Nursing (DON)/Risk Manager/QAA (Quality Assessment and Assurance) stated, On 5/03/23, according to the nurse [Staff A, Licensed Practical Nurse (LPN)] at 5:45 PM she couldn't locate the resident in his room. They checked room to room on unit three with the help of other staff that was here. They also searched on Unit 1 and Unit 2 and outside on the premises. They couldn't find the patient. The patient was ambulatory, come to Unit 1 and go out to the patio and enjoyed participating in activities. At 6:00PM they confirmed the patient could not be found in the building. Immediately, they activated CODE GREEN our code for elopement. We searched again the area, informed the Administrator and informed all my interdisciplinary team to come back to the facility to look for the patient. At 7:18 PM, we called the police and the son and the daughter. Somewhere between 7:30-7:35PM, we did a complete head count of every resident in the building to verify if anyone was missing. Everyone was here, except the resident. At 8:13 PM, the son came to the facility and we gave him emotional support and told him what transpired. At 8:30 PM, the staff came back to the facility from searching and we started the education on elopement and on abuse and neglect. Around 8:45PM, we reported to [ ] local agency about the incident. We initiated the [ ] local Immediate Report by the Social Services Director. At 9:00 PM, we assigned a staff to call all emergency rooms in the area to find the patient. We checked all exit doors around that time. We continued searching for the resident. The nurses did reassessments for all residents at elopement risk. He was considered an elopement risk. He was able to remove the wander guard and the doctor discontinued the order for the wander elopement alarm. Some staff went about searching until 2:00AM in the morning and I continued searching until 5:00 AM in the morning. We identified four residents who were elopement risk but one had expired over the weekend. All elopements books were audited and updated. I gave instructions to do head count three times every shift (in the morning when they come in, 4 hours after that and before they leave for the day and then endorse it to the next staff). On 5/04/23 at 8:00 AM we started replacing the fence on the back patio because it was short and we replaced another gate on the back patio on yesterday. We now have the security guard who started on 5/05/23 to keep an eye on the back patio. We called the emergency rooms to locate the resident. We continued the education on 105120 Page 27 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few elopement and abuse and neglect policy and we did an elopement drill. At 3:00 pm on 5/05/23 we continued to call the hospital emergency room. Around 8:00PM, the residents son came to talk to me and the Administrator. On 5/05/23, at 5:00 PM, the security guard company sent a guard to be stationed on the back patio. Security guard will be on the back patio for 24 hours, seven days a week. CNA will be assigned to be outside on the front patio 24 hours, seven days a week. At 4:40 PM, the police officer called the Administrator that the resident was found in [ ] local city. He was knocking on peoples doors in the neighborhood where he was found. At 4:45 PM, I called the family, the son and told him the father was found by a certain police officer and he went to the [ ] local city to pick him up. Around 7:00PM, I called the son and he said the father is with me and we are on our way to the facility. He took him to eat something first and he said he wanted his father to go the local emergency room (ER) for evaluation. At 8:35PM, resident arrived in the company of his son. We readmitted the resident, reassessed him, offered fluids, food, ADLs and medications. We put him on 1 to 1. When he came back he was dirty, we tried to get him to take a shower but he refused. We asked the son to help us get him cleaned up. At 10:35 PM he was sent out to the [ ] local hospital ER for evaluation with the son by his bedside. Before this incident, the door to the back patio off Unit 2, the residents were able to push the door and go outside, there was no alarm. On 5/03/23, we started working on upgrading the door and the alarm system and it was not finished until mid-afternoon 5/04/23. The resident went outside the back door off of Unit 2. The back door off the Unit 2 now has an alarm and code. Only the staff has the code. We plan on changing the code every 2 months and we are checking doors everyday by the Maintenance Director. On 5/08/23 at 11:58 AM, the Administrator stated, There was an elopement, we did a search of the area. We called the police and let them know about a missing person, we let the family and the physician know. The police came and gave us the paperwork for the missing person. We started doing drill that night into the weekend and on elopement, abuse and neglect. On Friday 5/05/23 we got the call that he had been found. The police brought him back. He was then sent to the hospital for evaluation. Staff will be back to work on Wednesday, 5/10/23. I am not able to pull the footage because it overrides. I didn't get a chance to take still photos of the video. On 5/08/23 at 12:06 PM, the Social Service Director stated, On Wednesday about 5:45-5:50PM, the nursing staff reported that the resident was not in the building. The nursing staff as well as the managerial staff conducted an in-house search for the resident, we could not find him in the facility. Therefore, staff went out on foot, our cars to check the surrounding areas. We came back, we were not able to find the resident. We notified the police, doctor, family member. We continued to search for him. We called the hospitals in the area and no one found him. The police came and spoke with me, they met with the nursing staff assigned to the resident. I called [ ] local agency to make them aware and reported it. Friday afternoon about 4:40PM, the Administrator received a call from [ ] local police had found the resident. The resident returned to the facility around 7:00PM accompanied by his son. He was assessed by the nursing staff, the physician was made aware that the resident was found and the son and physician were in agreement for him to be sent to [ ] local hospital for further evaluation. On 5/08/23 at 3:33 PM, Staff C, Registered Nurse (RN) for the 3:00 PM to 11:00 PM shift stated, When I came in on 5/03/23 I did my rounds on Unit 1 and Unit 2. I was going up to Unit 3 and met the cna (certified nursing assistant) in the elevator and she told me she noticed he was missing. We started looking in bathrooms, rooms, dining room, trash rooms, med rooms. When we didn't see him, I pulled his chart he was not signed out by any family member. I came and told the DON and he called Code Green. We looked on all units, the patio, the DON informed the family and police. I was so frantic I got in my car and drove around looking for the resident. I drove around for 2 105120 Page 28 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0835 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ½ hours looking for him and I didn't find him. When I came back, the police was here. On 5/05/23, I started the assessment and tried to clean him up. He was dirty and he had a smell. He didn't want us to clean him up, he went out of the room and said if you keep bothering me, I will go back downstairs to my son. The son came up and calmed him down, and he let us clean him. The son wanted him to go out to a [ ] local hospital for evaluation. We had put one to one in place for when he came back to the facility. No injuries were noted, he had very dry skin and red were noted. Transportation came and the son left with the resident to the hospital. On 5/09/23 at 8:23 AM, the Social Services Director stated, I was at the nurses' station with the nurse and I dialed the number for the son. We called the son, the voicemail was full and we could not leave a message. Then we proceeded to call the daughter who answered and the nurse told her about the incident. The resident's vision was impaired, he has cataracts. He did not have glasses. He had a Vision consult on 4/17/23 and the consult says he has cataracts. On 5/09/23 at 8:31 AM, Staff D Licensed Practical Nurse (LPN), Unit Manager 3 for the 7:00 AM to 3:00 PM shift stated, Like any other day, he ambulates. He likes to talk to other Spanish speaking residents. He goes downstairs to activities. Everyone in the building is aware that we need to keep an eye on him. There is nothing that is on a time schedule, the main thing is to keep him from the front door. He always talks about going to the bank. The week before he left and I told him he has money here. He went to the Business Office and they gave him $20.00 and he would carry it in his pocket. This was 8 days before he left. As far I know he didn't have any vision problems. As far I knew he was here in the facility all day. I saw him around 10:00 AM. I had already left for the day and they notified me he was missing because he didn't show up for dinner. I got in my car and came back immediately. I drove around the neighborhood looking for him. He went out the back door on Unit 2, took a chair, took off his shoes and used his toes to get in the grooves of the fence and climbed over. On 5/09/23 at 8:39 AM via telephone Staff A, LPN for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, I took his vital signs and gave him medications around 9:30 AM. He ate his breakfast. He walks up and down and goes downstairs on the patio. I didn't have to give him his medications until 1:00pm. He received medications at 9:00 am and 5:00pm. The CNA put his lunch tray in his room and she did not go back to see if he ate or not. She removed the lunch tray when it was time to give him his dinner tray. That's when she realized that he was missing. She came to me and said she didn't see him. I asked her did he eat and I saw his lunch tray. I said he didn't he eat and she said no. We went room to room. I called the supervisor and told him. I went in my car and rode all around and he was nowhere to be found. I can say the incident was negligence. I was praying that he would be found alive and God answered my prayers. On 5/09/23 at 8:47 AM via telephone Staff B, Certified Nursing Assistant (CNA) for the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shift stated, When I came on Wednesday to work I saw all my patients. I gave him his breakfast and he eat and I took up his tray. I put his lunch tray in the room because he was downstairs. He would come and eat the food. I went to the other patients and was taking care of them. Sometimes he would eat in the dining room upstairs. I have 11 patients to care of and he didn't listen. I tell him not to go downstairs, he don't listen to you. The camera showed he left at 10:30 AM. I was working a double shift on that day. When I put the dinner tray, I saw the lunch tray there and I said where is he. I don't see him. I went to the nurse and we started checking for him. On 5/09/23 at 9:03 AM, the Human Resources Manager stated, We couldn't see much because of the site where he jumped. He pulled a chair, to the fence and jumped over the fence. The incident occurred 105120 Page 29 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0835 according to the video around 10:37 AM. It was so quick. There was much not evidence on the video. We didn't get a clear picture of him because the camera didn't get the side of the patio. Level of Harm - Immediate jeopardy to resident health or safety On 5/10/23 at 10:06 AM, the Business Office Manager stated, He had a personal funds account and his check started coming here about a month ago. He came to me on 4/25/23 and he received $20.00. Residents Affected - Few The facility's immediate jeopardy removal plan included: The staff were In-serviced/trained on 5/03/23 for 3PM-11PM shift, 11PM-7AM shift for nurses and certified nursing assistants (CNA) and 5/04/23 for 7AM-3PM shift, 3PM-11PM shift and 11PM-7AM shift for nurses and CNAs regarding: Wandering precautions and wander/elopement alarm device, Abuse and neglect and Monitoring patients with exit seeking behaviors and elopement risk. On 5/4-7/23 on all shifts for nurses, cnas and all staff were in-serviced/trained on an elopement drill and abuse and neglect. A 24-hour security guard was brought in to monitor the back exits. The facility installed an alarm system that is audible at the nursing station and care areas were added to the exit door on Unit 2, to alert the staff of any residents trying to exit the door. Maintenance staff or their qualified designees, conduct daily door audits to ensure all door are in proper working order, including checking that the alarm is audible at the nursing station and care areas. A 6-foot fence was installed to the back end of the smoking area, to ensure that residents remain in the smoking area. The gate will be monitored by the patio area's CNA or designated staff member. A security guard has been assigned to watch the north-west gated area during the ongoing updates to the facility's security systems. An audit of all residents who reside in the facility was conducted to evaluate a risk for leaving the facility without informing staff and/or if they may desire to leave the facility. The nursing, therapy, social services, housekeeping and dietary departments were re-educated on the facility's policy and procedure of missing person protocol which include code green, ensuring that the wandering observation tool is used effectively per facility's protocol. The facility-initiated Staff re-education on 5/03/23 for all shifts regarding Abuse and Neglect policy. A 24-hour security guard was brought in to monitor the north-west gated area exits. Prompt re-training was initiated on 5/04/23 for all shifts regarding Abuse Reporting, Elopement, Abuse and Neglect and Reporting Elopement, Fire Exit Doors and Audible Alarms, Abuse and Neglect/Elopement Identifying Patients with Exit Seeking Behaviors, Endorsing and Monitoring of Exit Seeking Residents-Implementing 1:1, Close Monitoring and Code Green. The immediate jeopardy removal plan was verified as completed from May 8 - 10, 2023 by reviewing the above documentation; observing the back patio; observing the coded, audible alarm exit door on Unit 2; interviewing the security guard on the back patio; interviewing (16) staff members to verify they received elopement inservices, participated in elopement drills, inservice on checking wander guards, abuse and neglect inservices. The verification included RN's, LPN's, and CNA's from the 7-3, 3-11 and 11-7 shifts. Reviewed inservices and sign in sheets for: Date - 5/03/23; Title of the In-Service: Elopement Drill; Audience: All staff Date - 5/04/23; Title of the In-Service: Elopement; Elopement Drill; Audience: All staff Date - 5/04/23; Title of the In-Service: Neglect; Audience: All staff 105120 Page 30 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0835 Date - 5/05/23; Title of the In-Service: Neglect; Audience: All staff Level of Harm - Immediate jeopardy to resident health or safety Date - 5/05/23; Title of the In-Service: Elopement Drill; Audience: All staff Residents Affected - Few Date - 5/6-7/23; Title of the In-Service: Elopement Drill; Audience: All staff Date - 5/6-7/23; Title of the In-Service: Neglect; Audience: All staff 105120 Page 31 of 32 105120 05/10/2023 Serenity Bay Nursing and Rehabilitation Center 16650 W Dixie Hwy North Miami Beach, FL 33160

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action related to abuse neglect policies resulting in repeated deficient practice. The facility's history includes deficient practice for failing to develop and implement abuse and neglect policies. The facility was cited for develop and implement abuse and neglect policies in 2018. This repeated deficiency practice has the potential to affect any of the 107 residents residing in the facility. The findings included: Record review of the facility's Quality Assurance Performance Improvement (QAPI) Program Policy and Procedure (implemented November 2022) documented the following: Policy-This facility shall develop, implement and maintain an effective, comprehensive, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents; QAPI purpose is a type of quality management program which takes a systematic, interdisciplinary, comprehensive and data-driven approach to maintaining and improving safety and quality. Policy Explanation and Compliance Guidelines: 1) The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) Committee and a written QAPI Plan; 2) The QAA Committee shall be interdisciplinary and shall: b) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program; 3) b) Policies and procedures for feedback, data collection systems and monitoring, c) Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: i.) Tracking and measuring performance, iii.) Identifying and prioritizing quality deficiencies, iv.) Systematically analyzing underlying causes of systemic quality deficiencies and v.) Developing and implementing corrective action or performance improvement activities. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 2/10/23, 3/10/23, 4/14/23 and 5/03/23 documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON)/risk Manager, Admissions Coordinator, Rehab Director, Social Services Director, Dietitian, Business Office Manager, Activities Director, Food Service Director, MDS (Minimum Data Set) Coordinator, Maintenance Director, Housekeeping Director, Human Resources Manager and Licensed Nurses. Interview with the Director of Nursing/QAA on 5/10/23 at 1:14 PM. He stated, The QAA Committee meets every month on the first Wednesday of every month. The committee consist of the Medical Director, Administrator, DON and all interdisciplinary team members. The purpose of QAA is to track and trend and identify any gaps in the systems. 105120 Page 32 of 32