Villa Maria Nursing Center

nurse if he was in the room and she said no. We began to search, and we didn't find the patient we

jeopardy to resident health or know he was at risk for elopement. A procedure was put in place after the incident to take residents safety who are at risk for elopement back upstairs first then take the remaining residents.On 9/05/2025 at 9:03 AM, Staff G, Security Officer via telephone stated, I work 2:00 PM to 10:00 PM. I have been

of the building, make sure that not anybody isallowed to come in and out, I must watch them. We used to have both gates opened at the same time.

New procedure is to make sure one gate is opened at a time. On that day I had medical emergency working and the van was waiting to go out and there was another person trying to come into the building. I was looking at the ID for the person trying to come into the building and did not see anyone walking out of the gate. I only saw the person walking out when they showed me the video.On 9/05/2025 at 9:16 AM, Staff H, Receptionist via telephone stated, I work 3:00 PM to 8:00 PM. I have been working here for two years. On that day I came and checked my books for the patient.

They called me to page the Code Pink, and they told me to look and I didn't see anything. I did not see him at the door.

Any patient I see, I would check my book and call the nurse to come and get them. My responsibilities are to answer the phones and assist family members coming into the building. On 9/05/2025 at 9:38 AM, the Registered Nurse, Assistant Director of Nursing (ADON) stated, I work 8:00 AM to 4:00 PM. On 8/4 that day the daughter took the patient downstairs to the patio.

She left him with activities. We didn't really know if he was inactivities.

After the activities lady said she couldn't find the patient and announced code pink. We were looking for the patient in the stairs, around the building, everywhere.

After we couldn't find him, the social worker called the police. We continued looking for the patient, called the Administrator and the Risk Manager.

They found out the police found the patient and took him to [local hospital].

Pink band was on the patient. If the patient takes it off, we put it around the ankle.

His was on the ankle.On 9/05/2025 at 11:44 AM, the Registered Nurse, Director of Nursing (DON) stated, I got a call from [], the ADON, that there was an elopement and I told him that I would be there. As I was driving to the facility, I was searching for him. I took one of my nursing assistants and was informed he was at [hospital]. I went to the hospital to confirm he was there. I confirmed that he was there and spoke with the ER (Emergency Room) nurse and resident. He appeared to be stable, alert and responsive. I notified the daughter.

She wanted me to take him back to the facility, but I told her no and she must speak with the hospital. I came back to the facility and met with the team and started in-servicing staff on elopement.

The staff said they did everything, they called the code and did a search.

Our new procedure: In-service the security at the gate, that when one gate opens, the other one is closed.

Discussed more about elopement.

There should always be someone there when the patients are down for activities.

Ensured that the assignments for the nurses and the CNAs document who are at risk for elopement.On 9/05/2025 at 11:52 AM, the Administrator stated, I am two minutes from my house and get a call from the ADON that one of the residents was missing and they couldn't find him.

Code pink was called, and I turned around and came back.

The Engineering Director and I looked at the video footage. We saw the resident and how he was able to leave. He was in communication with one of the visitors and he was telling him to stop following him. We got a call from the police saying that he was found.

The facility communicated with the daughter and that he had been found.

After communicating with the daughter, she said that she didn't want anything to be done at the hospital and wanted him to come back to the facility. We also communicated with the medical director.

The daughter went to the hospital and brought him back to the facility. He was put on 1:1 and then transitioned to 30-minute rounding.

The Risk Manager was in-servicing the staff about the elopement and had a long conversation with the guard at the gate. We have a new process: One gate at time to be opened and the guards must put their eyes on who is leaving. We reviewed the books for people at elopement risk, but we also added the wanders.

When he left there was no one in the lobby to see him leave.

105232 09/05/2025

Villa Maria Nursing Center 1050 NE 125th Street North Miami, FL 33161

we put it around the ankle.

His was on the ankle. On 9/05/2025 at 11:52 AM, the Administrator stated,

Director and I looked at the video footage. We saw the resident and how he was able to leave. He was

from the police saying that he was found.

The facility communicated with the daughter and that he had been found.

After communicating with the daughter, she said that she didn't want anything to be done at the hospital and wanted him to come back to the facility. We also communicated with the medical director.

The daughter went to the hospital and brought him back to the facility. He was put on 1:1 and then transitioned to 30-minute rounding.

The next day formal in-services started, and we started a root cause and analysis. We looked at film and came up with solutions. We have a new process: One gate at time to be opened and the guards must put their eyes on who is leaving.

When he left there was no one in the lobby to see him leave.

105232 09/05/2025

Villa Maria Nursing Center 1050 NE 125th Street North Miami, FL 33161

corrective plans of action.

failed to identify quality concerns to implement effective plans of action related to adequate

for failing to supervise residents resulting in possible accidents.

The facility was cited for Free of Accident Hazards, Supervision, Devices, Administration and Quality Assurance and Assessment on July 31, 2025. On 8/04/2025, the facility was negligent and failed to provide adequate supervision and effective services to prevent the elopement of one (Resident #1) out of three sampled residents with exit seeking behaviors, resulting in Resident #1 eloping from the facility at 4:24 PM, through an electronic gate in the front of the facility on foot undetected.

These repeated deficient practices have the potential to affect any of the 191 residents residing in the facility.The findings included: Record review of the facility's Quality Assurance Performance Improvement (QAPI) Program Policy and Procedure (implemented December 2004) 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.

Guidelines for Governance and Leadership: 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 6/17/25, 7/15/25 and 8/19/25 documented the facility had a QAA Committee meeting monthly.

Attendees included: Executive Director, DON, Medical Director, Director of Social Services, Director of Activities, Dietitian, MDS Coordinator, Director of Case Management, Director of Housekeeping/Laundry Services, Risk Manager, Infection Control, Director of Health Information Management, Fiscal Services, Pharmacist, Data Analyst, Laboratories and Community Liaison.Interview with the Director of Nursing/QAA on 9/05/25 at 2:27 PM.

She stated, The QAA Committee meet monthly and we meet on the third Tuesday of the month.

The committee members consist of the Administrator, DON, Medical Director and Department Heads.

The purpose of the QAA committee is to bring forth any concerns that we may have and that we may need to address patient concerns and quality of care.