Health inspection·February 15, 2024

F 0550 eat. Moving forward I will re-educate staff regarding appropriate assisting residents with meals. Level of Harm - Minimal harm or potential for actual harm On 02/12/2024 at 08:05 AM, Staff E, CNA was observed standing next to Resident# 62 while assisting to feed the resident lunch. Residents Affected - Few Record review of demographic face sheet revealed Resident #62 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included Moderate protein-calorie malnutrition and Vitamin D deficiency. Record review of Discharge Return Anticipated MDS dated [DATE] revealed Section C for cognitive patterns revealed a Brief Interview Mental Status (BIMS) score of undetermined out of a scale of 0-15, that indicated severe cognitive impairment. Section K for swallowing/nutrition status revealed Resident #62 received a therapeutic diet. Section GG for Functional Abilities and Goals revealed Resident #62 required setup and clean up assistance from staff for eating. Review of care plan initiated on 01/11/21 and revised on 12/4/23 revealed Resident#62 has a problem with Activities of Daily Living (ADL) self-care deficit, supervision with tray set up for feeding. Review of physician orders revealed a diet order dated 1/27/24 for regular .renal diet. On 02/12/24 at 12:35 PM Staff G, CNA (translated by Staff D) stated she has been working at the facility for 4 years, she understood that standing while feeding a resident is a dignity issue for the resident. Staff G further stated she stood while feeding Resident #62 because that resident normally eats independently. I am short, moving forward I will sit when assisting any resident to eat. On 02/12/24 at 12:45 PM, Staff D, LPN stated: Staff are to be seated when assisting residents to eat, this is part of dignity for all residents. Staff D stated she will reinforce this concept with the CNAs. On 02/15/24 at 08:38 AM, the Director of Nursing (DON) stated that staff who assist residents with meals should be seated while assisting. An in-service was completed on 01/23/24 for direct care staff regarding Techniques for assisting with feeding and which included being seated while assisting a resident to eat. I will reeducate staff about being seated while assisting a resident to eat. I will round during mealtimes to ensure staff are sitting while feeding residents. I am aware that it is a dignity issue whenever a staff member is standing while assisting to feed a resident. Review of Policy and Procedure entitled, Assistance with Meals dated 04/1/23. Policy statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy In Policy Interpretation and Implementation: Dining Room Residents: 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. Not standing over residents while assisting them with meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105498 If continuation sheet Page 2 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Susanna Wesley Health Center 5300 W 16th Avenue Hialeah, FL 33012 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to electronically transmit the Discharge- Return Non-Anticipated Minimum Data Set (MDS) to Centers of Medicare and Medicaid (CMS) within 14 days for one (Resident # 10) out of two residents whose assessments were investigated. Resident #10 who was discharged to the community but the MDS was not transmitted. There were 120 residents residing in the facility at the time of survey. Residents Affected - Few The findings included: Record review of the clinical records for Resident # 10 revealed the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Review of the Discharge Return Non-Anticipated MDS Section A Identification Information dated 10/01/2023 revealed the resident was discharged to the community (home). The Discharge Return Non-Anticipated MDS dated [DATE] was not transmitted within 14 days after completion. During an interview with the MDS Coordinator on 02/14/24 at 01:19 PM. She reported that the assessment was completed but not transmitted after completion and she forgot to transmit on time after completion. She stated she will validate and transmit the assessment. Interview with MDS Coordinator on 02/14/2024 at 1:30 PM. She stated that the MDS was transmitted. Further record review after the above interview revealed, the Discharge Return Non-Anticipated MDS dated [DATE] was transmitted on 02/14/2024. Review of Policy and Procedures for Minimum Date Set (MDS)3.0 Completion and Transmission dated implemented 04/01/2023 revealed Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. Policy Explanation and Compliance Guidelines: f- discharge assessment-completed using the discharge date as the Assessment Reference Date (ARD). Must completed within 14 days of the discharge date /ARD. Transmission Requirements: a-All assessment shall be transmitted to the designated CMS system (iQIES) within 14 days of completion. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105498 If continuation sheet Page 3 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Susanna Wesley Health Center 5300 W 16th Avenue Hialeah, FL 33012 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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** 2) Record review of the Demographic Face Sheet for Resident #44 documented the resident was admitted on [DATE] with diagnoses that include but not limited to: epilepsy, dementia, schizophrenia, bipolar disorder. Residents Affected - Few Review of the Physician's Order Sheet (POS) and Medication Administration Records (MAR) for December 2023, January 2024 and February 2024 documented the resident was receiving medications that include but not limited to the following, Olanzapine 5mg (milligrams) tab (tablet) 1 tab via tube feeding once a day for schizophrenia. Review of the Minimum Data Service (MDS) Annual assessment dated [DATE] for Resident #44 documented the resident's Mental Status (BIMS) Summary Score was 09, indicating cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions was not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. Review of the Psychotropic Drug Use Care Plan for Resident #44, written 11/04/2022 documented the resident was currently receiving antipsychotics, antidepressants, and antianxiety medications. Review of the PASRR Level I Screen for Resident #44 dated on 7/16/2019 documented: Section I: PASRR Screen Decision-Making: Mental illness of anxiety disorder and schizophrenia; Section II: Other Indications for PASRR Screen Decision-Making: 1) Is there an indication the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage was coded Yes and 3) Is there an indication that the individual has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following? A. Psychiatric treatment more intensive than outpatient care was coded Yes. The PASRR Level I Screen dated on 10/24/2022 documented: Section I: PASRR Screen Decision-Making: Schizophrenia and Section II: Other Indications for PASRR Screen Decision-Making: 1) Is there an indication the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage was coded Yes. Review of the PASRR Level II Determination Summary Reports for Resident #44 dated 7/24/2019 and 11/01/2022 documented the resident met the state definition of serious mental illness and specialized services were not recommended. On 2/15/2024 at 1:47 PM, the Social Services Director stated, I screen the Level I to see if they qualify for a Level II. If they need a Level II, I submit the paperwork for the Level II. I started July 2023. He did have two Level II's done on 7/24/2019 and 11/01/2022. On 2/15/2024 at 2:09 PM, the Registered Nurse (RN), Minimum Data Service (MDS) Coordinator confirmed the resident did receive a PASSR Level II on 7/24/2019 and 11/01/2022 and the MDS Annual, dated 10/13/2023 is incorrect for a PASSR Level II. On 2/15/2024 at 2:32 PM, the Director of Nursing (DON) confirmed the resident had PASSR Level I done on 7/16/2019 and 10/24/2022 and the Level II was done on 7/24/2019 and 11/01/2022. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105498 If continuation sheet Page 4 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Susanna Wesley Health Center 5300 W 16th Avenue Hialeah, FL 33012 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Based on record reviews and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (Resident #117 and Resident #44) out of four residents reviewed for residents' assessments. There were 120 residents residing in the facility at the time of the survey. The findings include: Residents Affected - Few 1) In a record review for Resident #117, the resident was admitted to the facility on [DATE] and was discharged home on [DATE]. Record review of medical diagnosis include heart failure, muscle/ wasting atrophy (gradual decline) of left/ right upper arms and left/right lower leg. Review of physician orders revealed Resident #117 was to be discharged home on 1/12/2024 with home health with a Registered Nurse, physical therapist, and occupational therapist with a wheelchair, walker, and commode. Review of the Care plan that started on 10/04/2023 revealed that Resident #117 overall goal was established during the assessment process and expects to be discharged home with daughter. Review of progress notes documented by Social Services dated 01/12/2024 at 11:59 AM revealed that the resident was scheduled for discharge home today with her daughter. On 01/12/2024 at 01:22 PM, a Nurse stated Resident #117 was in stable condition and was discharged from the facility with daughter to home. Review of documentation titled physician discharge summary revealed Resident #117 received rehab, special wound care, a restorative nursing program, and safety measures (fall management). Order for immediate care of Resident #117 was to be discharged home. The prognosis condition improved. The discharge diagnosis was discharged to home. The discharge date documented was 1/12/2024. Review of Minimum Data Set, dated [DATE] discharge return not anticipated revealed in section A: Identification Information. It stated Resident #117 was discharged , return not anticipated, and it was planned. The discharge date was 01/12/2024 to a short-term general hospital. On 02/14/2024 at 01:29 PM, in an interview the MDS Coordinator was asked where Resident #117 was discharged to. The MDS coordinator reviewed the progress notes and stated: The resident was discharged home on 1/12/24. It was coded as hospital, but the resident went home. I will send a modification. Review of facility's policy titled Conducting an accurate resident assessment. Date implemented 4/1/23. The policy statement stated the purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. In the section titled 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. 7) Whether the Minimum Data Set assessments are manually completed, or computer-generated following data entry, each individual assessor is responsible for certifying the accuracy of responses relative to resident's condition and discharge or entry status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105498 If continuation sheet Page 5 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Susanna Wesley Health Center 5300 W 16th Avenue Hialeah, FL 33012 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, records review, and interviews. The facility failed to ensure medications were securely stored, as evidenced by fourteen loose pills and two half pills were found on one out of two medication carts checked. There were 120 residents residing in the facility at the time of the survey. The findings included: On 02/13/2024 at 02:48 PM, during observation and interview with Staff A, LPN (Licensed Practical Nurse) on the third-floor medication cart two. Fourteen loose pills and two half pills were found. (photographic evidence). Staff A, LPN was asked: What is the facility's policy for checking and cleaning medications carts? Staff A LPN stated, The 11-7 shift cleans the cart and on weekends. I check the medications, check for expired meds, and that medications are up to date. I cleaned the cart. When I find loose pills. We dispose of them in the drug buster. In an Interview on 02/13/24 at 03:13 PM, the Nursing Supervisor was asked: What is the facility's policy for checking and cleaning medication carts? The nursing Supervisor stated: The Pharmacist was here yesterday to check on medication carts. The 11-7 shift cleans and picks out any loose pills. We have a sign-in log for that. It documents staff cleaning the cart and how many loose pills were found. On 02/14/24 at 02:57 PM. In an interview with the Director of Nursing, the findings of the third-floor's second cart were discussed, and the photographic evidence was shown. The DON was asked: What is the facility's policy for checking carts for loose pills and cleaning them? The Director of Nursing stated: Two consultant Pharmacists came to check all our medication carts. Our census is full. From Friday to Monday, I had five residents admitted to the facility. We have too many bingo cards in the medication carts. When nurses are pulling the medication bingo cards in and out. Pills can come out. I have a system in place. We check the carts on the night shift every night. The nurses will remove all the medication bingo cards, clean the carts, and check the carts. We check carts daily for expired meds, remove all loose pills, clean bottles, check for spills, and check discrepancies. They have time without interruptions. I've spoken to the pharmacy to request bigger carts because our carts are jam-packed with bingo cards. Review of the medication cart check sheet for February 2024 revealed medication cart two on the third floor. From February 1,2024 to February 14, 2024 on the 11-7 shift, it was noted to be initialed and stated in the comments section that that the cart was cleaned, and loose pills were removed. Review of the pharmacist medication area inspection on 2/12/24 revealed that on cart two. Four expired medications were advised to be replaced, liquid medication to be cleaned, and opened /undated medication packets were addressed by the nurse. Review of documentation from Pharmacy ticket #975. Dated February 12, 2024 at 3:41 PM. Status Closed. The facility is requesting larger carts as the current carts can no longer accommodate their needs and are packed to capacity. The request is for larger carts, not additional carts. Review of facility's policy and procedure titled Medication Storage dated March 2023. The policy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105498 If continuation sheet Page 6 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Susanna Wesley Health Center 5300 W 16th Avenue Hialeah, FL 33012 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm statement stated medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with the Florida Department of Health guidelines. In section procedure, C. Medication will be stored in an orderly, organized manner in a clean area. E. Medication will be stored in the original, labeled containers received from pharmacy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105498 If continuation sheet Page 7 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Susanna Wesley Health Center 5300 W 16th Avenue Hialeah, FL 33012 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure the Third Floor Pantry refrigerator used exclusively for the resident's was maintained in a sanitary manner as evidenced by opened undated milk carton observed. This has the potential to affect fifty-five residents out of fifty-seven residents who eat orally residing on the Third floor. The findings included: Observation of the Third Floor Nourishment Pantry on 2/14/2024 at 7:33 AM revealed a pint carton of 2% reduced milk was opened and not dated. Photographic evidence submitted. Observation and interview with Staff C, Registered Nurse (RN), Nursing Supervisor on 2/14/2024 at 7:34 AM. She confirmed the milk carton was open and not dated. She stated, I forgot to check the refrigerator. They said they just opened the milk. Interview with the Dietary Supervisor on 2/14/2024 at 7:58 AM. She revealed that nursing is responsible for making sure the pantry refrigerators are in order and are contained properly. Interview with the Registered Dietitian on 2/14/2024 at 8:56 AM revealed that once a milk carton is opened, it should be labeled and dated with a use by date and a date when it was opened. Record review of the Food Storage Policy and Procedure (revision date April 2023); Policy Statement-Foods shall be stored in a manner that complies with safe food handling practices; Policy Interpretation and Implementation-4) All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) and 9) Food items and snacks kept on the nursing units must be maintained as indicated below: d) Beverages must be dated when opened and discarded after twenty-four (24) hours. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105498 If continuation sheet Page 8 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Susanna Wesley Health Center 5300 W 16th Avenue Hialeah, FL 33012 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to ensure the arbitration agreements presented to three residents (Resident number 70, Resident number 84, and Resident number 220) out of three residents reviewed informed residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. There were 120 residents residing in the facility at the time of the survey. Residents Affected - Few The findings included: Record review of the Binding Arbitration Agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents or their representatives to enter into an arbitration agreement, 3) The facility had residents who entered a binding agreement on or after 9/16/2019 and 4) The Admissions Coordinator is responsible for the binding arbitration agreements. Review of the facility Voluntary Arbitration Agreement documented the following: Resident number 70 signed and dated on 6/02/2020, Resident number 84 signed and dated on 7/17/2023 and Resident number 220 signed and dated on 1/23/2024 failed to show the arbitration agreements allowed the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. On 2/14/2024 at 9:45 AM, interview and record review with the Admissions Coordinator confirmed that the Voluntary Arbitration Agreement forms did not document the binding arbitration agreement allowing the resident or anyone else to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105498 If continuation sheet Page 9 of 10 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Susanna Wesley Health Center 5300 W 16th Avenue Hialeah, FL 33012 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations, interview, and record review the facility failed to provide a safe environment for residents on the second floor, as evidenced one out of one Biohazard room observed on the facility's second floor door was kept unlocked. This has the potential to affect the 58 residents residing on the second floor during the survey. The findings included: On 02/14/2024 at 10:15 AM The door of the Biohazard room on the second floor was not locked. On 02/14/2024 at 10:15 AM, Staff B observed entering Biohazard room by pushing the door open. The Biohazard room door unlocked while staff inside. On 02/14/2024 at 10:20 AM; One staff member observed pushing the door of the Biohazard room open and entering. The Biohazard room door was unlocked while staff inside. On 02/14/2024 at 10:25 AM, Staff B, Certified Nursing Assistant stated there is a key to open the door; I didn't use it because the door was open. On 02/14/2024 at 10:26 AM, Staff C, Registered Nurse Supervisor stated: the Biohazard room door should always be locked to prevent residents from entering the room and encountering hazardous material. The key is kept in the drawer. Staff C stated that she will reinforce with staff to use key to enter, and to ensure the door is locked while inside and when leaving. On 02/14/2024 at 4:24 PM, the Director of Environmental Services stated the door to the Biohazard room should be locked at all times to maintain the safety of residents. On 02/15/2024 at 08:19 AM, the Director (DON) stated that the Biohazard room door should be closed and always locked for the safety of the residents; an in-service was started on 2/14/2024 for all direct care staff and housekeeping to reinforce that the Biohazard room door should be locked. On 02/15/2024 at 08:46 AM, the Administrator stated, The Biohazard room door should always be locked to ensure the safety of our residents. The Administrator also revealed that the locks for each Biohazard room were replaced with new locks and the keys are kept at the nursing station. Review of Policy and Procedure, entitled Biohazard Waste Room Management dated 4/1/2023: All biohazard rooms will have a biohazard sign for identification and the doors will be kept locked. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105498 If continuation sheet Page 10 of 10