Every finding on record at Autumn Lake Healthcare at Oakview

Based on observation, record review, policy review, and interview, it was determined that the facility failed to follow professional standards of nursing practice for medication administration and for timely, accurate clinical documentation. This was evident for 3 residents (Resident #20, Resident #6, and Resident 140) of 38 residents reviewed during the survey investigation and medication administration facility task.The findings include: 1) On 07/29/2026 at 11:02 AM a reviewing the Resident #140 electronic health record (EHR) revealed the resident was sent to the hospital for further medical evaluation on the morning of 02/15/26. Licensed Practical Nurse (LPN) #45 documented details of the incident on 02/15/36 at 7:09 PM and documented the time as 8:09 AM. A review of the Change in Condition revealed LPN #46 failed to document Resident #140 had a foley catheter and the amount and type of oxygen the resident received. On 07/30/26 at 2:48 PM a review of the Documentation Policy revealed the licensed staff should indicate documentation is a late entry if it occurs after the fact outside acceptable time limits. Documentation should be accurate, relevant, and complete containing sufficient details about the residents' care and/or responses to care. On 07/30/26 at 10:29 AM during an interview with LPN #31 the surveyor asked if a resident had a decline and had to be stabilized or sent out for further medical evaluation, when is the nurse expected to document. LPN #31 verbalized immediately after the incident occurred the nurse should document. They would not wait until the end of the shift to ensure they remembered everything that happened. They would document in real time. On 08/03/26 at 10:51 AM during an interview with Director of Nursing (DON) #2 verbalized the incident was an emergency and the nurses had to complete the documentation. The surveyor asked who is responsible for reviewing the nursing documentation. DON #2 reported every day they do clinical and review the reports. If anything is standing out they would review the documentation. They discuss the patients and review the 24-hour report and review the orders to make sure they are carried out. If there were any changes they make sure they follow up (F/U) with it. 2) On 7/29/2026 at 9:11 AM, the surveyors observed Staff #20 prepare scheduled morning gastrostomy tube (G-tube) medications and administer them to Resident #20 through a G-tube. A G-tube is a medical device placed through the skin of the abdomen directly into the stomach to deliver liquid nutrition, fluids, and medications when a person cannot safely eat or swallow by mouth. Staff #20 prepared the 2 liquid medications in a separate medication cup. However, Staff #20 placed all 3 tablet medications into one crushing bag, crushed them together, and administered the combined medications through the G-tube in a single administration. On 7/30/2026 at 1:36 PM, the surveyor reviewed the facility's Medication Administration via Enteral Tube policy. The policy stated, Each medication will be administered separately, not combined or added to an enteral feeding formula. On 8/3/2026 at 9:30 AM, the surveyor informed the second-floor Unit Manager that the G-tube tablet medications had been crushed together and administered together instead of being prepared and administered separately. The Unit Manager stated that education would be provided to the nurse. On 8/3/2026 at 9:36 AM, the surveyor informed the Director of Nursing (DON) of the observation. The DON stated that staff education would be provided. 3) On 7/29/2026 at 1:05 PM, the record review revealed a physician order for bilateral heel booties while in bed for Resident #6 on 7/28/2026. On 7/29/2026 at 1:33 PM, the surveyor observed Resident #6 in bed without the bilateral heel booties in place. Resident #6 confirmed that the facility had ordered the booties. On 7/30/2026 at 10:07 AM, the surveyor again observed Resident #6 in bed without the heel booties. On 7/30/2026 at 10:12 AM, the surveyor interviewed the second-floor Unit Manager, who was working on the floor. The Unit Manager stated that the heel booties had been ordered and would check whether they had been delivered. Approximately 10 minutes later, the Unit Manager brought the heel booties and stated that the manager would apply the booties to Resident #6. On 7/30/2026 at 12:05 PM, the surveyor reviewed Resident #6's Treatment Administration Record (TAR). The review of the TAR revealed that staff documented the heel booties as applied during the evening and night shifts on 7/28/2026, and on the day, evening, and night shifts of 7/29/26. On 7/30/2026 at 12:28 PM, the surveyor interviewed Staff #20, who had documented the heel booties as applied on the day shift on 7/29/2026. Staff #20 stated that Resident #6's booties were not available yesterday and that the documentation was entered by mistake. On 7/31/2026 at 2:09 PM, the surveyor informed the DON that the TAR indicated the heel booties had been applied for 5 shifts on 7/28/2026 and 7/29/2026 when they had not been in place due to unavailability. When asked about documentation expectations, the DON stated that staff required education on accurate clinical documentation.

Based on staff interviews and surveyor record review it was determined that the facility failed to report an injury of unknown source to the State Licensing Agency - Office of Health Care Quality (OHCQ) within the required time. This finding was found to be evident for 1 (Resident #32) out of 3 Residents reviewed for allegation of abuse in reference to Incident #2728940.The findings include:Office of Health Care Quality (OHCQ) is a state agency under the Maryland Department of Health that monitors and surveys health care facilities and community-based programs to protect public health, safety, and care standards. Responsibilities of QHCQ include licenses and certifies nursing homes, conducting routine and complaint driven health and safety inspections, investigating reported care deficiencies, neglect, or operational violations, and maintaining public licensee directories and compliant survey reports. The surveyor reviewed the facility's investigation file on 7/30/2026 at 1:45 PM for the facility reported incident (FRI) dated 1/28/2026 for the allegation of abuse/injury of unknown source (discoloration to hand/fracture of 4th digit left hand) for Resident #32. Licensed Nursing Home Administrator (LNHA) submitted an initial report to OHCQ on 1/28/2026 at 3:02 PM as date stamped on the email documentation. LNHA submitted the final investigation report on 1/30/2026 at 2:00 PM. The radiology report from PDI Health (mobile x-ray company) for Resident #32 revealed an examination date and time of 1/27/2026 at 13:12 PM and a reported date and time of 1/27/2026 at 15:02 PM. The radiology report indicated the following findings: left hand, there is a nondisplaced fracture of the proximal phalanx of the fourth digit, conclusions: fracture is noted. OHCQ was not notified of the fracture until 1/28/2026 at 3:02 PM approximately 24 hours later after the radiology report of the left hand. Furthermore, on 1/25/2026 at 14:38 PM Resident #32's left hand was observed with blood filled blisters at the base of 2nd, 3rd, 4th and 5th digits. The surveyor interviewed the LNHA regarding the allegation of abuse/injury of unknown source for Resident #32 at 2:35 PM on 7/30/2026 and conveyed to the LNHA that the allegation of physical abuse/injury of unknown source was not reported to the OHCQ within the required 2-hour time frame. LNHA acknowledged the surveyor and indicated that the staff did not report this injury timely, and that the expectation was to report allegations of abuse and injury of unknown source within the required timeframe.No additional information was provided by the facility at the time of exit.

Based on record review and staff interview, it was determined the facility failed to accurately code the residents' status in the Minimum Data Set Assessment. This was evident for 4 (Resident #138, Resident #1, Resident #4 and Resident #10) out of 8 residents reviewed for Accuracy of Assessments.The findings include: Aripiprazole (often sold under the brand name Abilify) is an atypical or second-generation antipsychotic medication. It's used to treat various mental health conditions such as Bipolar. Fluoxetine hydrochloride is a widely used antidepressant medication, commonly known by its brand name Prozac. It is commonly used to treat depression. Minimum Data Set (MDS) The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1). On 7/25/2025 at 1:29 PM, a review of Resident #138's progress notes was conducted. Multiple notes on 5/11/2025 indicate that the resident discharged home Against Medical Advice (AMA). On 7/25/2025 at 1:31 PM, a review of the Resident #138's Minimum Data Set (MDS) was conducted. In the Discharge return not anticipated MDS assessment submitted on 5/19/2025, it was coded under Section A-A2105 that the discharge location of the resident was Short-Term General Hospital. On 7/28/2025 at 8:33 AM, an interview with the MDS coordinator (Staff #3) was conducted. When asked how they determined which discharge location to code the Resident in the MDS assessment, Staff #3 stated that they look at Nursing Notes, Social Services notes, and looks at the census for discharge information. This surveyor confirmed Resident #138's progress notes and MDS findings with Staff #3. Staff #3 stated that they should have coded Resident #138's discharge location as Home and not Short Term General Hospital. 2). On 7/29/2025 at 11:56 AM a review of Resident #1's medical record was conducted. The resident's active orders were Aripiprazole Oral Tablet 5mg daily for bipolar disorder and Fluoxetine hydrochloride 20 mg daily for Depression. Review of Resident #1's Medication Administration Record (MAR) revealed that the resident was currently taking medications daily indicated for bipolar disorder and Depression. Review of Resident #1's psychiatric notes dated 7/2/2025 indicated an assessment and plan to continue treatment for Bipolar as well as Depression Disorder. On 7/30/2025 at 11:02 AM further review of Resident #1's MDS completed on 7/6/2025 failed to reflect an active diagnosis of Depression Disorder. On 7/30/2025 at 12:10 PM an interview with Staff #3, MDS coordinator, was conducted. She reported that she did not look at the psychiatric note dated 7/2/25 and that she missed coding Depression disorder on MDS. On 7/30/2025 at 12:35 PM the Facility Administrator and Director of Nursing (DON) were notified of the concerns. 3). A review of Resident #4's medical record on 07/29/2025 at 12:28 PM, revealed that a MDS was completed on 07/03/2025. The MDS coded that the resident, under Section N0421 (medications received), was receiving an anticoagulant in the last 7 days. On 07/29/25 at 12:33, a review of the resident's orders, at the time of the MDS review period, revealed that there was no order for anticoagulation medications. On 07/29/2025 at 12:35 PM, a review of the resident's Medication Administration Record (MAR) for June and July of 2025 revealed that the resident was not receiving anticoagulant medications. The MDS Coordinator (staff #3) was interviewed on 07/30/2025 at 11:14 AM. During the interview she stated that she would review the residents MAR and based on what she found is how she would code the MDS. On 07/30/2025 at 11:48, during a second interview, the MDS Coordinator confirmed that the MDS was coded incorrectly. After surveyor intervention, the MDS was corrected. 4). On 07/29/2025 at 11:56 AM, a review of Resident #10's medical record revealed an MDS that was completed 5/14/25. The MDS coded that the resident, under Section N0421 (medications received), was receiving an anticoagulant. On 07/29/2025 at 11:58 AM, a review of the resident's orders, at the time of the MDS review period, revealed that there was no order for anticoagulation medications. On 07/29/2025 at 12:04, a review of the resident's Medication Administration Record (MAR) for April and May of 2025 revealed that the resident was not receiving anticoagulant medications.During an interview with the MDS Coordinator (staff #3) on 07/30/2025 at 11:14 AM, she stated that she would review the residents MAR and based on what she found is how she would code the MDS. On 07/30/2025 at 11:48, during a second interview, the MDS Coordinator confirmed that the MDS was coded incorrectly. After surveyor intervention, the MDS was corrected.

Based on observations, facility documentation, and staff interviews, it was determined that the facility failed to maintain refrigerated food temperatures at a safe level. This was found to be evident for the 3rd floor nourishment room refrigerator during the annual survey.The findings include:PHF (Potentially Hazardous Food) and TCS (Time/Temperature Control for Safety) foods are foods that require specific time and temperature controls to limit the growth of harmful microorganisms. According to the Food and Drug Administration recommendations and regulations, TCS/PHF foods must be stored at 41 F or below.The 3rd floor nourishment room refrigerator was observed by the survey team on 7/24/2025 at 10:24 AM. A sign located on the outside of the refrigerator stated the refrigerator is reserved for resident's only. It was observed by the surveyor that the thermostat inside the refrigerator read 52 F. Review of the temperature logbook located on top of the refrigerator showed signed documentation from staff that the refrigerator temperature was 38 F on 7/24/2025.The 3rd floor nourishment room refrigerator was observed on 7/25/2025 at 11:48 AM by the survey team and the thermostat inside the refrigerator read a temperature of 50 F. The logbook was reviewed and showed the documented temperature by staff was 38 F on that day. An additional observation on 7/28/2025 at 12:50 PM by the survey team revealed the thermostat inside the refrigerator read 54 F but the logbook kept by the facility had a documented temperature of 38 F.Geriatric Nursing Assistant (GNA) #11 was interviewed on 7/28/2025 at 1:09 PM and asked to show where food brought from outside the facility is stored for residents on the 3rd floor. GNA #11 showed the surveyor the 3rd floor nourishment room refrigerator and stated that outside food is dated and labeled and placed inside the refrigerator for residents. At 1:12 PM, the 3rd floor unit manager registered nurse (RN) #12 was asked to show where resident food brought from outside the facility is stored. RN #12 showed the surveyor the same refrigerator as GNA #11. RN #12 was asked if the thermostat inside the refrigerator is used for documenting temperatures and they answered yes. Surveyor addressed concerns to RN #12 about the actual reading temperature of the thermostat and what was being documented in the temperature logbook. RN #12 stated they were not aware of temperature discrepancies and stated that night shift nurse is responsible for documenting the daily temperature of the refrigerator. They also stated they would inform maintenance and educate staff.The surveyor addressed concerns about the refrigerator temperature with the Director of Nursing (DON) on 7/28/2025 at 1:46 PM. They stated the would talk with the 3rd floor unit manager and make maintenance aware.

Based on observation and interview, it was determined that the facility failed to have a process in place to ensure that handrails were securely attached to the wall. This was evident for 1 of 1 unit observed.The findings include:An observation of the 2nd floor nursing unit on 7/24/25 at 8:15 AM revealed a loose handrail that was directly across the hallway from the elevator doors. The metal bracket that secured the handrail to the wall was pulled away with the drywall attached. The handrail to the right, when stepping out of the elevator, was loose. The metal bracket that secured the handrail to the wall was pulled away with drywall attached.During an observation of the loose handrails on the 2nd floor nursing unit on 8/5/25 at 12:34 PM with the Maintenance Director and the Nursing Home Administrator (NHA), they acknowledged the concerns. The maintenance director reported that he had instructed his maintenance workers to check the handrails periodically, however there was no documentation of this task. He stated that he was going to create something to have them sign off that they were checking the handrails in the future.

Based on observations and interviews, it was determined that the facility failed to maintain a safe and sanitary environment for a resident. This was evident for 1 (Resident #126) of 8 residents reviewed for safe, sanitary and functional environment during the recertification survey.The findings include:On 7/24/2025 at 1:15 PM An observation of Resident #126's room was conducted. The surveyor noted a strong musty smell and observed black substance underneath the resident's bathroom sink. On 8/01/2025 at 10:30 AM Another room observation was conducted with 2 surveyors. Upon opening the door, both surveyors noted a strong moldy smell coming from Resident #126's room. The second-floor Unit manager, Staff #4, was asked to enter the room with the surveyors. She also acknowledged the strong moldy odor coming from the resident's room. The bathroom floor was noted to have black substances. On 8/01/2025 at 10:30 AM An interview with Staff #4 was conducted. Staff #4 reported that she became aware of the mold problem in the resident's bathroom last week. She added that at times Resident #126 does not allow staff to enter or stay in their room for too long. When asked if the Director of Nursing (DON) was aware of the mold concern, Staff #4 stated that the DON was not aware, but she would notify her of the concern immediately. On 8/04/2025 at 9:20 AM The Facility Administrator was made aware of the safe environment concerns.

Based on interviews and record review, it was determined that the facility failed to accommodate resident's food preferences and intolerances. This was evident for 1 (Resident #133) of 3 residents reviewed for food choices during the recertification survey. The findings include:On 8/01/2025 at 10:00 AM During the resident council meeting, a facility task that was completed during the survey, Resident #133 reported that the facility kept serving them Lactaid milk and oatmeal even though they have communicated their dislikes and preferences to Staff #5, dietary manager, several times. Furthermore, Resident #133 stated that for breakfast on 8/01/25 they received oatmeal and Lactaid milk, 2 items that they dislike because they cause diarrhea episodes. The resident reported that they do not eat the oatmeal provided by the facility because it was cooked with milk, and that they have requested cream of wheat instead.On 8/01/2025 at 11:00 AM A review of Resident #133's medical record was conducted. The review revealed that the resident had lactose intolerance. On 8/01/2025 at 1:00 PM An Interview with staff #16 was conducted. They confirmed that Resident #133 had Lactaid milk and oatmeal on their breakfast tray this morning. On 8/01/2025 at 1:24 PM An Interview with the dietary manager was conducted. He confirmed that he had a discussion with Resident #133 regarding their dislike of oatmeal and Lactaid milk last week, and that he was not sure why the resident was still served the disliked items. On 8/01/2025 at 2:04 PM Administrator and Director of Nursing (DON) were notified of these concerns.

Based on observations, record review, and interviews, it was determined that the facility staff failed to properly assess and monitor a resident's wander guard. This was evident for 1 (Resident #39) of 2 residents reviewed for elopement during the recertification survey.The findings include:On 7/24/2025 at 3:33 PM While conducting second floor unit observations, Resident #39 approached the surveyor and said that they would like to go home. The resident stated, this place feels like a prison. The surveyor then redirected the resident to the second-floor nurses' station. On 7/24/2025 at 3:43 PM A review of Resident #39's medical record was conducted. The review indicated that the resident scored as high risk for elopement on 6/17/25 with a note that stated the resident had multiple attempts to elope. On 7/17/25, there was an order entry to check wander guard placement every shift daily. On 7/30/2025 at 7:11 AM Surveyor observed Resident #39 walking around the first floor. When surveyor asked Resident #39 if they needed assistance, the resident replied that they were desperate to leave the facility. The resident had no wander guard on the right ankle. On 7/30/2025 at 7:25 AM A brief review of the resident's record revealed that facility staff had checked placement of the wander guard on 7/29/25, morning, afternoon and nightshift. On 7/30/2025 at 7:38 AM The surveyor redirected Resident #39 to the second floor. Staff #23, the night shift supervisor, confirmed that the resident did not have a wander guard on. When asked where the wander guard was, Resident #39 replied that they threw the wander guard in the toilet 4 days ago because they felt like they were being tracked. On 7/30/2025 at 7:49 AM An interview with the Staff #7 was conducted. She acknowledged that she documented that the wander guard was on the Resident #39's right ankle without checking for the wander guard placement. On 7/30/2025 at 8:12 AM An interview with the Facility Administrator was conducted. He stated that Resident #39 was at a very high risk for elopement, and that he was aware of the resident's request to leave the facility. The surveyor then briefed the administrator of the wander guard concerns identified.

Based on record review and interview, it was determined that the facility failed to prevent a resident with cognitive impairment from leaving the facility unsupervised. This was evident for 1 (#143) of 3 residents reviewed for elopement.The findings include:On 7/28/25 at 9:49 AM a review of the facility's policy titled, Elopement, Risk Prevention and Management of Missing Residents, implemented 1/15/20 revealed that staff were to conduct an elopement assessment upon admission, readmission, quarterly, and upon significant change. If a resident was deemed a low risk (0-8 points) for elopement there was no intervention implemented. If they are deemed to be at risk (9-10 points) the IDT was to review the assessment and determine the care plan interventions and if they were a high-risk (11 or more points) staff were to implement a wander guard bracelet per standing order. A closed medical record review for Resident #143 on 7/25/25 1:55 PM revealed a transfer report from the acute care hospital the documented the resident had been at another facility owned by the same corporate company and was admitted for hypoglycemia (low sugar levels in the blood). Review of the document revealed the resident had a diagnosis of dementia The H&P from Suburban Hospital DOS 1/30/24 revealed a diagnosis of dementia and the plan for treatment was Paxil (antidepressant) and tramadol (pain medication). A History and Physical assessment from the hospital was included and read that the resident had the diagnosis of dementia and the treatment plan noted the resident was on Paxil and Tramadol to treat the dementia. A review of the electronic medical record on 7/25/25 at 2:05 PM revealed an admit/readmit screener dated 2/5/24 that read the resident had a diagnosis of dementia, the resident was able to walk in their room, in the hallways on and off the unit with limited assistance, and no wheelchair was marked. Review of a wandering/elopement assessment that was completed on 2/5/24 by License Practical Nurse (LPN) Staff #24. She failed to note that the resident had a diagnosis of dementia which was 5 points versus 0 and she failed to mark that the resident was ambulatory which was another 3 points versus 1 point. These inaccurate responses gave the resident a score of 2 points making the resident a low risk, however it should have been 9 points making the resident at risk for elopement and according to the policy the IDT would have reviewed the resident and determined the appropriate intervention to ensure the resident's safety. The baseline care plan that was completed on 4/6/24 by Unit Manager (UM) Staff #12 noted the resident did not have a wheelchair, the cognitive status was blank, and the resident was marked as not an elopement risk. On 2/6/24 the attending physician deemed the resident not to have capacity to make decisions. On 2/7/24 a second physician confirmed this finding. There were no additional wandering/elopement assessments completed until 4/5/24. The facility's investigation file for self-reported incident #MD00335640 was reviewed on 7/25/25 at 10:15 AM. The initial report read that Resident #143 was found outside in the parking lot on 4/5/24 at 4:05 PM attached to the report was a Resident sign in and out log for 4/5/24, that showed the resident had signed at 4:03 PM. A handwritten interview with Receptionist Staff #25 revealed the resident wanted to go outside and because the resident wasn't on the elopement risk list, she allowed the resident to sign out. Staff #25 reported the resident was going up the hill and was about 100 ft from the property line when an employee drove up behind the resident. She reported the resident was brought back inside by the UM Staff #12. On the same handwritten note it read the resident was reassessed and determined to be an elopement risk and a wander guard bracelet (causes alarm to sound if the resident is too close to the front doors) was put on the resident. LPN #24 was interviewed on 7/31/25 at 2:47 PM regarding the wandering/elopement risk assessment she completed on 2/5/24 for Resident #143. She referred to the transfer report in the medical record as the report she used to complete the wander elopement assessment. She reported that she missed the diagnosis of dementia on the elopement sheet. When asked about the resident's mobility, she stated she marked it wrong on the elopement assessment because she remembers the resident was up and walking on the day of admission. While reviewing the wandering/elopement risk assessment she was asked if she thought the resident was an elopement risk. She stated she did not think s/he was because the resident was not exit seeking on admission. Reviewed the inaccurate answers and the score should have been a 9 deeming the resident at risk for elopement, she was asked what she would have done differently? She stated she would have called the front desk immediately to make them aware, notified her supervisor, and monitored the resident more closely. The concerns were reviewed with the Director of Nursing (DON) on 7/31/25 at 3:21 PM. The DON stated that the ambulatory status of the resident may be difficult to determine. However, when shown the facility admission screening documentation and LPN #24's report that the resident had been walking around the day of admission, she would have expected the resident to be marked ambulatory. In addition, she confirmed the diagnosis of dementia should have been marked appropriately making the resident at risk for elopement.

Based on record review and staff interviews, it was determined that the facility failed to: 1) report an injury of unknown origin to the state agency in a timely manner, and 2) ensure that incidents of alleged abuse were reported to the state agency in a timely manner. This was found to be evident in 3 (Incident 335642, Incident 335653and Complaint 335655) of 29 intakes investigated during the survey. The findings include: 1) On 8/1/2025 at 12:26 PM, documentation provided by facility regarding Incident 335642 was reviewed by the survey team involving Resident #121. Per record review, Resident #121 was noted to have discoloration around their left eye during AM care on 7/20/2024 by staff. Resident #121 has a diagnosis of dementia and could not provide information on injury at the time it was noticed. Further record review revealed that the Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the injury of unknown origin on 7/22/2024. Email documentation showed that the initial report of the injury of unknown origin was sent to the state survey agency on 7/22/2024 at 4:44 PM. The NHA was interviewed on 8/1/2025 at 2:30 PM. They stated that it’s the facility’s expectation that staff inform the DON and NHA of alleged abuse or injuries of unknown origin immediately so the appropriate state agencies can be notified, and the facility can begin their investigation. The NHA stated the notification of these incidents has been an on-going problem and they have had multiple in-services with staff on this issue. Surveyor addressed concern with the NHA that facility did not report the injury of unknown origin in the appropriate timeframe. 2a.) On 8/4/2025 at 8:04 AM, documentation provided by the facility regarding Incident 335653 was reviewed by the survey team involving Resident #104. Per record review, on 3/18/2025 at 12 PM, Resident #104 was witnessed by Licensed Practical Nurse (LPN) #1 walking next to another resident that was sitting in a chair outside of their room. The resident in the chair then hit Resident #104 in the abdomen resulting in them falling and sustaining a hematoma to their head. Further record review showed the NHA was made aware of the incident on 3/19/2025 at 10:00 AM. Per email confirmation, the incident was reported to the state survey agency on 3/19/2025 at 1:20 PM.On 8/4/2025 at 3:40 PM, the surveyor addressed concerns about the alleged resident-to-resident abuse not being reported in the 2-hour time frame to the state survey agency to the NHA. The NHA verbally substantiated the resident-to-resident abuse and stated that the facility’s expectation is to report the alleged abuse within the 2-hour timeframe. 2b.) On 8/1/2025 at 8:32 AM, a review of Complaint #335655 was conducted. The complainant, Resident #44, questioned a deduction of $1000 from their funds on 9/22/2022. On 8/1/2025 at 2:24 PM, an interview with the Business office manager (Staff #19) was conducted. When asked about when they became aware of the resident's concern, Staff #19 stated that a grievance came from the social services department, and it was investigated to see if a receipt or record of this transaction was in their records. It was not found, so on 4/4/2025 I reported this to Nursing Home Administrator (NHA). A copy of email notification made to NHA dated 4/4/2025 and a copy of the grievance from Resident #44 dated 3/28/2025 was provided to the survey team. On 8/1/2025 at 2:48 PM, during an interview with the NHA, when asked if they were aware of Resident #44's concern regarding $1000 missing finances from their account in September of 2022. The NHA stated they were aware and have been trying to get the issue resolved with their corporate finance group. When asked if they reported the alleged incident of misappropriation of Resident #44's funds to the proper authorities on April 4th, 2025; the NHA stated that they did not.

Based on record review, resident interviews, and staff interviews, it was determined the facility failed to protect the resident from misappropriation of property. This was evident for 1 out of 1 resident reviewed for personal funds.The findings include:On 8/1/2025 at 8:32 AM, a review of Complaint #335655 was conducted. The complainant, Resident #44, questioned a deduction of $1000 from their funds on 9/22/2022. On 8/1/2025 at 12:44 PM, an interview was conducted with Resident #44 in regards to Complaint #335655. Resident #44 reiterated wants to know what a $1000 dollar charge was for on 9/22/2022. They stated that they have talked to the Business office and the corporate financial group about the $1000 dollar charge. The resident provided the survey team with a copy of their quarterly statement with the questioned $1000 deduction from their account labeled Personal Needs Items. The resident stated when they requested a copy of the receipt for the transaction, the facility was unable to provide it.On 8/1/2025 at 2:24 PM, an Interview was conducted with the Business Office Manager (Staff #19). When asking the Staff #19 how they became aware of this incident, they stated a complaint was received by the social services department in the form of a grievance from Resident #44 on 3/28/2025. They stated that the grievance was investigated to see if a receipt and record of this transaction was in the business office records, but it was not found. The Business office manager stated that on 4/4/2025, they reported this to the Nursing Home Administrator (NHA). A copy of the email notification made to the NHA and the original grievance from Resident #44 was provided to the survey team. The grievance form was dated 3/28/2025. The email was dated on 4/4/2025. When asked if they have provided Resident #44 with a response or resolution to their concern, Staff #19 stated No. On 8/1/2025 at 2:48 PM, during an interview with the NHA, when asked if they were aware of Resident #44's concern regarding $1000 missing finances from their account in September of 2022. The NHA stated they were aware and have been trying to get the issue resolved with their corporate finance group. When asked if they reported the alleged incident of misappropriation of Resident #44's funds to the proper authorities on April 4th, 2025; the NHA stated that they did not. On 8/04/2025 at 9:10 AM, an interview was conducted with the NHA. When asked to provide an update on Resident #44's concern, the NHA stated that on 8/1/2025 they requested their finance group to process the return of funds if they are unable to provide the facility with records of the receipt of the 1000 dollar Personal Needs Items transaction.

Based on review of facility investigations, resident medical records, and interviews with facility staff, it was determined that the facility failed to ensure that residents remained free of abuse. This was true for 3 (Resident #104, Resident #21 and Resident #146) of 11 residents reviewed for abuse during the survey.The Findings include:1) The facility's investigation related to facility reported incident 335653 was reviewed by the survey team on 8/4/2025 at 8:04 AM. Per medical record review and review of the facility investigation, on 3/18/2025 at 12 PM, Licensed Practical Nurse (LPN) #1 witnessed Resident #104 walk out of their room and walk next to Resident #33, who was sitting in a chair outside of their room. LPN #1 then witnessed Resident #33 hit Resident #104 in the abdomen which caused them to fall and sustain a hematoma to their head and be sent to the emergency room for evaluation. LPN #1 was interviewed by the survey team on 8/4/2025 at 2:28 PM. LPN #1 confirmed she witnessed Resident #33 push Resident #104 unprovoked, who then fell to the floor and sustained an injury. 2) The facility's investigation related to facility reported incident 335654 was reviewed by the survey team on 8/4/2025 at 9:53 AM. In the investigation, the facility substantiated through witnesses (LPN #20, Geriatric Nursing Assistant (GNA) #21, GNA #22) that Resident #33 pushed Resident #21 which resulted in Resident #21 falling to the floor and being sent to the emergency room due to pain. On 8/4/2025 at 3:27 PM, GNA #21 was interviewed by the survey team about the incident. GNA #21 stated that Resident #21 was seating in a chair and got up when Resident #33 sat down in the chair. Resident #21 then walked back to the seat when Resident #33 stood up and pushed Resident #21 who fell to the ground. On 8/4/2025 at 3:40 PM, the Nursing Home Administrator (NHA) was interviewed by the survey team. The NHA verbally stated that both incidents of alleged resident to resident abuse were substantiated through their respective investigations. 3) A medical record review for Resident #146 on 7/29/25 at 7:54 PM revealed the resident had a diagnosis of dementia and resided on the locked unit. On 7/29/25 at 8:14 PM a review of the facility’s investigation file revealed the initial report form that read the facility received an allegation of abuse involving Resident #146 on 12/6/24 at 7:55 PM. According to the final report form, a family member of a resident who resided on the locked unit, was trying to find the charge nurse to let them out of the locked unit and observed the nurse slapping the Resident #146. The family member reported what they saw to facility staff. The nurse was asked to leave the facility immediately and was terminated when the abuse was substantiated. The resident no longer resided in the facility. An attempt was made on 8/5/25 at 10:22 AM to call the family member who had witnessed and reported the incident, but it was unsuccessful. During an interview with the Director of Nursing (DON) on 8/5/25 at 10:25 AM, she confirmed the findings. She stated that the family member, who had been coming to the facility for a long time, was visibly upset by the incident and believable.

Based on record review, resident interviews, and staff interviews, it was determined the facility failed to record and make prompt efforts to resolve grievances. This was evident for 1 out of 1 resident reviewed for personal funds. The findings include: On 8/1/2025 at 8:32 AM, a review of Complaint #335655 was conducted. The complainant, Resident #44, questioned a deduction of $1000 from their funds on 9/22/2022. On 8/1/2025 at 12:44 PM, an interview was conducted with Resident #44 in regards to Complaint #335655. Resident #44 reiterated wants to know what a $1000 dollar charge was for on 9/22/2022. They stated that they have talked to the Business office and the corporate financial group about the $1000 dollar charge. The resident provided the survey team with a copy of their quarterly statement with the questioned $1000 deduction from their account labeled Personal Needs Items. The resident stated when they requested a copy of the receipt for the transaction, the facility was unable to provide it. On 8/1/2025 at 2:24 PM, an Interview was conducted with the Business Office Manager (Staff #19). When asking the Staff #19 how they became aware of this incident, they stated a complaint was received by the social services department in the form of a grievance from Resident #44 on 3/28/2025. They stated that the grievance was investigated to see if a receipt and record of this transaction was in the business office records, but It was not found. The Business office manager stated that on 4/4/2025, they reported this to the Nursing Home Administrator (NHA). A copy of the email notification made to the NHA and the original grievance from Resident #44 was provided to the survey team. The grievance form was dated 3/28/2025. The email was dated on 4/4/2025. When asked if they have provided Resident #44 with a response or resolution to their concern, Staff #19 stated No. On 8/1/2025 at 2:48 PM, during an interview with the NHA, when asked if they were aware of Resident #44's concern regarding $1000 missing finances from their account in September of 2022. The NHA stated they were aware and have been trying to get the issue resolved with their corporate finance group. When asked if they reported the alleged incident of misappropriation of Resident #44's funds to the proper authorities on April 4th, 2025; the NHA stated that they did not.

Number of residents sampled: Number of residents cited: Based on record review, resident interview, and staff interview, it was determined that the facility failed to maintain proper bookkeeping techniques as evidenced by not giving the resident or retaining a copy of a receipt of a transaction. This was evident for 1 (Resident #44) out of 1 resident reviewed for personal funds. The findings include: On 8/1/2025 at 8:32 AM, a review of Complaint #335655 was conducted. The complainant, Resident #44, questioned a deduction of $1000 from his funds on 9/22/2022. On 8/1/2025 at 12:44 PM, an interview was conducted with Resident #44 in regards to Complaint #335655. Resident #44 reiterated wants to know what a $1000 dollar charge was for on 9/22/2022. They stated that they have talked to the Business office and the corporate financial group about the $1000 dollar charge. The resident provided the survey team with a copy of his quarterly statement with the questioned $1000 deduction from his account labeled Personal Needs Items. The resident stated when he requested a copy of the receipt for the transaction, the facility was unable to provide it. On 8/1/2025 at 2:24 PM, an Interview was conducted with the Business Office Manager (Staff #19). When asking the Staff #19 if and when they became aware of Resident #44's concern, they stated a complaint was received by the social services department in the form of a grievance from Resident #44 on 3/28/2025. They stated that the grievance was investigated to see if a receipt and record of the $1000 transaction labeled Personal Needs Items was in the business office records, but It was not found. The Business office manager stated that on 4/4/2025, they reported this to the Nursing Home Administrator (NHA). A copy of the email notification made to the NHA and the original grievance from Resident #44 was provided to the survey team. The grievance form was dated 3/28/2025. The email was dated on 4/4/2025. When asked if they have provided Resident #44 with a response to his concern in writing, Staff #19 stated No.

Based on resident interview, facility documentation review, and staff interviews, it was determined that the facility failed to ensure that a resident's requested shower preference was honored. That was found to be evident in 1 (Resident #11) of 3 residents reviewed for choices during the annual survey. The findings Include: On 7/24/2025 at 10:30 AM, Resident #11 was interviewed by the survey team. When questioned by the surveyor if they had received a shower this week, Resident #11 shook their head no. When the resident was asked if they would like to receive showers, the resident nodded their head and said yes. On 7/28/2025 at 10:30 AM, Resident #11's medical record was reviewed by the surveyor. The resident had an order for bi-weekly showers during day shift on Mondays and Thursdays. Review of the documentation survey report for May 2025, June 2025, and July 2025 showed the resident was documented as having bed baths on scheduled shower days. Further review of Resident #11's records revealed no documentation of their refusal to shower. On 7/28/2025 at 12:54 PM, Resident #11 was asked by surveyor if they received their scheduled shower for the day and they stated no. When asked if they received a bed bath for the day, the resident replied yes. The resident stated to the surveyor that they would like a shower. On 7/28/2025 at 12:58 PM, Licensed Practical Nurse (LPN) #13 was interviewed by the survey team, in attendance was the Assistant Director of Nursing (ADON) and the 3rd floor unit manager registered nurse (RN) #12. When asked why Resident #11 received a bed bath on a scheduled shower day, LPN #12 stated the resident wants to get into their power chair quickly in the morning and prefers bed baths. Surveyor addressed to staff the lack of documentation showing bed baths as the resident's preference and Resident #11's desire to receive their shower on schedule shower days. The ADON stated they would go talk with the resident. On 7/28/2025 at 2:11 PM, the surveyor's concern with Resident #11 not receiving showers on their scheduled days was addressed with the Director of Nursing (DON). The DON stated she will educate staff about honoring Resident #11's preferences.

Based on review of pertinent documentation, observation, and interviews with resident and staff, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated resident preferences. This was evident for 5 (Resident # 112, Resident # 49, Resident # 25, Resident #2, Resident #59) out of 6 residents on 5 of the 6 units at the facility reviewed for food during a survey. This has the potential to affect all residents. The findings include: 1. Resident #112 was admitted to the facility for rehabilitation and wound care. An observation of resident's menu ticket and tray was made on 10/16/23 at 12:16 PM. The observation revealed that the resident had milk listed on his/her menu ticket; however, there was no milk on his/her tray. On 10/18/23 at 12:38 PM, an additional observation of Resident #112's menu ticket and tray were made. This observation revealed that milk was included on the menu ticket; however, the observation failed to reveal that the resident was provided milk. On 10/19/23 at 9:44 AM, a third observation of Resident #112's meal ticket was made. The observation revealed that the residents' menu ticket included milk and dry cereal and did not include orange juice. However, observation of the breakfast provided to the resident revealed dry cereal, and orange juice, but no milk. During a brief interview with Resident # 112, he/she reported that he/she had not requested any substitutes for his/her breakfast and that he/she did not drink orange juice because he/she was a diabetic. On 10/19/23 at 10:30 AM, the Kitchen manager, staff #51, was interviewed. During the interview, he reported that, due to a traffic accident, the milk was not delivered today. He reported that the facility purchased milk from a local store but had run out before Resident # 112 room was served. He reported that he was not sure why the resident did not receive milk for the last three days. On 10/20/23 at 9:12 AM, the Dietician (eligible) Staff # 38 was interviewed. She reported that she was unaware of any residents not receiving milk, as indicated on the menu ticket. She confirmed that increased protein was indicated for resident # 112 due to the resident having a wound. In addition, she confirmed that orange juice should be limited to a Liberalized Diabetic. On 10/31/23 at 12:56 PM, the surveyor observed Resident #112 during lunch. The resident had been served meatloaf, peas, roasted potatoes, and mixed melon. The lunch ticket for the meal was still on the tray. The lunch ticket had today's date at the top and stated that the resident was supposed to be served harvest beets, mashed potatoes, oven fried chicken, and watermelon. None of the items on the ticket corresponded to the items in the meal that was served to the resident. Furthermore, there was a list of preferences at the top of the lunch ticket that specified no melon. Neither the watermelon on the ticket nor the mixed melon that was served to the resident followed this preference. Resident #112 was interviewed and that time and stated that the tickets are always wrong. And I'm served melon all the time even though I don't want it. On 10/31/23 at 1:06 PM, Unit Manager (UM) #3 was interviewed in Resident #112's room. During the interview, UM #3 confirmed that the resident's meal ticket was different than the items that were served to the resident. 2. Resident # 49 was admitted to the facility for rehabilitation and received dialysis as an outpatient. During an interview on 10/24/23 at 12:13 PM, the resident reported that he/she often had received orange juice for breakfast, but that he was not supposed to because he/she was on dialysis. He/she stated that he/she did not drink orange juice. An observation was made on 10/24/23 at 12:52 PM of Resident #49's menu ticket and breakfast tray. The observation of the menu ticket revealed that milk had been included on the menu ticket, and orange juice was not listed on the menu ticket. Observation of the resident's tray revealed that the resident received orange juice for breakfast and no milk. During the observation, the resident reported that the staff never asked him/her if he wanted orange juice; they just served it a couple of times a week. On 10/26/23 at 8:39 AM, an additional observation of Resident #49's menu ticket and tray was made. The observation revealed that his/her menu ticket included garlic bread and did not include apple cranberry juice. Observation of his/her tray failed to reveal garlic bread but did include apple cranberry juice. During the observation, the resident reported that he/she did not request any alterations to his/her meal. Review of Resident #49's diet orders on 10/24/23 revealed an order dated 2/23/22 for a liberalized renal diet. On 10/23/23 at 01:14 PM, the Dietician (eligible) Staff # 38 was interviewed. During the interview, she was asked about special considerations that are included with a renal diet; she replied, that the diet would avoid high potassium diet. This would include orange juice, tomatoes, potatoes, and bananas. 3. Resident # 25 was a long-term resident of the facility with moderate cognitive decline. On 11/01/23 at 8:05 AM, an observation was made of Resident #25's menu ticket and tray. Observation of the menu ticket revealed oatmeal, chopped waffles, orange juice, whole milk, coffee, and diet sugar. Further review of the menu ticket revealed the resident was on a liberalized diabetic with no added salt (NAS)- chopped diet. However, observation of the tray provided to the resident served scrambled eggs, chopped meat, and a whole waffle. On 11/1/23,a review of orders for Resident #25 revealed a diet order dated 1/27/23 for a diet of liberalized diabetic NAS- chopped. 4. On 11/01/23 at 8:40 AM, an observation was made of Resident # 2's menu ticket and breakfast tray. Observation revealed that the resident had oatmeal on his/her tray, however, the oatmeal was not on the menu ticket. On 11/01/23 at 8:42 AM, GNA, Staff #49 was interviewed while serving Resident #2's breakfast. During the interview, she confirmed that the oatmeal was served but not on the menu ticket. She reported she knew the resident could eat the oatmeal because the resident was on a regular diet. GNA #49 did not know why the oatmeal was omitted from the menu ticket. She reported that the resident did not request any changes in breakfast. 0n 11/1/23 a review of the dietary orders for Resident #2 revealed an order dated 3/7/33 for a liberalized diabetic diet, regular texture. On 11/01/23 at 1:00 PM, the Corporate Dietary Director, a Registered Dietitian, was interviewed. During the interview, the surveyor reviewed the discrepancies in what was written on the kitchen's menu, resident meal tickets, and the menus provided to the residents. She reported that that a liberalized diet has less restrictions and allows the resident to make more choices. In addition, a liberalized diet may increase the resident's caloric intake in situations where the resident needs to gain weight. She also reported that the facility follows the guidelines from Dietary Guidelines Maryland of Health and Mental Hygiene Diet. However, unless the resident has made a specific request, the expectation is that the resident should be provided with the food items that are written on the menu ticket. 5. Resident # 59 was admitted to the facility following a hospital stay. On 10/23/23 at 9:44 AM, an observation was made of the resident's breakfast tray and menu ticket. The observation of the menu ticket included oatmeal. Observation of the breakfast tray failed to reveal that oatmeal was provided. Further observation of Resident #59's meal menu and tray on 10/24/23 at 12:34 PM revealed a menu ticket that included garlic bread; however, there was no garlic bread provided to the resident. During the observation, the resident reported that he/she did not request any changes to the above meals. On 11/02/23 at 8:46 AM, the above concerns were discussed with the Kitchen Manager staff # 51. During the interview, he reported that the expectation was that the residents would receive all the food items that are on the menu tickets. On 11/03/23 at 10:28 AM, the Dietician eligible staff #38 was interviewed. During the interview, she reported that she conducted monthly audits of the diet orders. The audits included reconciling the electronic record of the ordered diet and the menu tickets. Staff 38 provided documentation of the audits. She also reported that she does weekly observations of the residents to ensure the residents menu tickets matches what the residents are provided, and she had no concerns with the results of these observations. However, she reported that she does not document these observations.

Based on interview of facility staff, it was determined the facility failed to ensure that a full-time qualified dietetic service supervisor for oversight of food preparation and daily kitchen operation and a certified Registered Dietician for nutrition management. This has the potential to affect all residents. The findings include: On 10/19/23 at 10:21 AM, an interview with the Kitchen Manager staff #51 revealed that he was not clinically qualified as per Federal and state regulations. During the interview, he reported that he had been in his position for two and a half years. He reported that he had completed his coursework, but had not yet passed the Certified Dietary Manager (CDM) exam. He stated he planned to take the exam in November 2023. On 10/23/23 at 1:14 PM, an interview with Dietician (eligible) staff # 28, revealed that she was not clinically qualified as per Federal and state regulations. During the interview, she reported that she had been in her position since June 2023. She continued that she was eligible to take the registered dietitian exam, but had not taken it yet. On 10/23/23 at 1:27 PM, the [NAME] President of Operations and the Administrator were interviewed. They reported the previous CDM left the facility around September 2021. They also were aware that the Dietitian was not currently certified as a registered dietician. They added that the dietitian does have a consulting dietician available when needed. On 10/23/23 at 1:14 PM, during an interview with the facility Registered Dietitian (eligible) Staff # 28, reported that a registered dietitian consultant was available by phone from her company Nutraco. Staff #28 reported that the last time the consultant had been on site at the facility had been about 2 months ago.

Based on observation, medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately documented. This was evident for 3 (Resident #79, #24, #7) of 47 residents reviewed during the survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure that each Resident receives the care they need. 1) On 10/23/23 at 1:33 PM, a review of Resident #79's medical record revealed the resident was admitted to the facility in November 2021 for rehabilitation following an acute hospitalization for a traumatic brain injury, and multiple fractures resulting from a motor vehicle accident, and resided in the facility for long term care. In a History of Present Illness note on 11/8/21, the physician documented Resident #79 had a past medical history which included Hepatitis C (viral infection that attacks the liver). Continued review of the medical record failed to reveal any further documentation to indicate whether or not the resident's diagnosis was active. There was no documentation found to indicate that the resident was receiving treatment or being monitored for the disease. Review of Resident #79's most recent quarterly MDS, with an ARD (assessment reference date) of 7/20/23. Section G, Cognitive Patterns, documented Resident #79's Brief Interview for Memory Status (BIMS) summary score was 6, indicating the resident had severe cognitive impairment. Section I, Active Diagnose coded Infections, I2400 Viral Hepatitis was an active diagnosis. Review of Resident #79's care plans failed to reveal that a comprehensive care plan had been developed to address the resident's hepatitis. On 10/24/23 at 2:33 PM, during an interview, when asked whether Resident #79's diagnosis of Hepatitis C (Hep. C) was an active diagnosis, Staff #35, RN, 3rd floor Unit Manager, initially stated h/she was unaware of the resident having the diagnosis, then stated that h/she recalled that Resident #79's Hep. C was not an active diagnosis. On 10/24/23 at 3:36 PM, during an interview, Staff #40, LPN, MDS Coordinator, indicated Resident #79 had the Hep. C since h/she was discharged from the hospital, and the diagnosis was documented in the physician's visit notes, Hepatitis was coded as an active diagnosis. On 10/25/23 at 12:32 PM, during an interview, Staff #31, Attending Physician, confirmed the resident had a past history of Hepatitis C, and stated Resident #79 had never exhibited an symptoms of advanced liver disease. Staff #31 indicated that at the present time, the resident's Hepatitis was not active, or being treated, and if the physician suspected the disease was active, s/he would refer the resident to a specialist. On 10/30/23 at 11:06 AM, the above concerns were again reviewed with the MDS coordinator, Staff #40, who agreed that though there was physician documentation that Resident #79 had a history of hepatis C, the diagnosis was inactive as the resident was not receiving any treatment or nursing monitoring for the diagnosis. 48259 2) On 10/30/23 at 11:20 AM, a medical record review for Resident # 24 revealed a Minimum Data Set (MDS) assessment, dated 9/26/23, that documented seven days of antibiotic use in section N. A continued review of Resident #24's medical record showed a medication administration record for September 2023 with no documentation of antibiotic use for the observation period of the 9/26/23 MDS assessment. Further review of the record failed to show an attending provider's order for antibiotics in September 2023. On 10/30/23 at 11:38 AM, an interview was conducted with staff # 40, MDS Coordinator. During the interview, she confirmed that seven days of antibiotic use recorded on Resident # 24's MDS assessment, dated 9/26/23, was documented in error and that she would modify the assessment. 48470 3) Resident #7 is a long-term care resident of the facility admitted in 2023. On 10/17/23 at 11:16 AM, a review of the residents MDS assessment, with a reference date of 9/5/23, revealed section F Preferences for customary routine and Activities was completed by a registered nurse (RN staff #52). Further review of Section F revealed dashes in the areas where assessment answers were to be documented. On 10/19/23 at 8:55 AM, the Activities Director (AD staff# 21) was interviewed about her process and was asked specifically about the MDS assessment done for Resident #7 with a reference date of 9/5/23. The AD reported that she was responsible for the MDS assessments for all residents in the facility under activities and she didn't know who Staff #52 was. She also reported that she does not delegate this task and remembers doing it for Resident #7 but does not know why it was not in the resident's medical records. The concern was discussed with the AD that Resident #7 was not assessed for any of the questions in section F of the MDS assessment done on 9/5/23. The AD staff #21 acknowledged the concern of the surveyor and indicated that she was aware of the regulations. On 11/03/23 at 12:30 PM, the identified concern was also discussed with the Director of Nursing and up until that time, no additional documentation or revision was provided by the AD staff #21. Cross reference to F 679

Based on medical record review and staff interview, it was determined the facility failed to notify residents or their representatives in writing of the reason for transfer and document that notification in the medical record. This was evident for 3 (#104, #142, #96) of 3 residents reviewed for hospitalization . The findings include: On 10/25/23 at 8:21 AM, a review of the Resident #104's medical record revealed the resident was admitted to the facility in April 2023, and following his/her admission, had been transferred to the hospital on 9/15/23, returned to the facility on [DATE], then transferred to the hospital on 9/25/23 and returned to the facility on [DATE]. Continued review of the medical record failed to reveal evidence that written notification of the resident's hospital transfer had been provided to Resident #104 and the resident's representative. On 10/25/23 at 10:55 AM, during an interview, Staff # 35, RN, 3rd floor Unit Manager (UM), stated when a resident was transferred to the hospital, the nurses completed had a SNF (skilled nursing facility) to Hospital Transfer Form, which included a checklist of the documents the nurse was to send with the resident upon transfer to the hospital, and provided the surveyor with a copy of the form. Review of the form's transfer checklist revealed a notice of transfer was not included on the form. At that time, when asked if a written notification of transfer was provided to the resident and their representatives when the resident was transferred to the hospital, Staff #35 stated that a written transfer notice was not included with the documents nursing sent with the resident on transfer, and for the surveyor to check with social services. On 10/25/23 at 10:55 AM, during an interview, Staff # 35, RN, 3rd floor Unit Manager (UM), stated when a resident was transferred to the hospital, the nurses completed had a SNF (skilled nursing facility) to Hospital Transfer Form, which included a checklist of the documents the nurse was to send with the resident upon transfer to the hospital, and provided the surveyor with a copy of the form. Review of the form's transfer checklist revealed a notice of transfer was not included on the form. At that time, when asked if a written notification of transfer was provided to the resident and their representatives when the resident was transferred to the hospital, Staff #35 stated that a written transfer notice was not included with the documents nursing sent with the resident on transfer, and for the surveyor to check with social services. On 10/25/23 at 2:02 PM, during an interview, Staff #19, Social Services Designee stated that he/she was not responsible for providing residents and their representative with a written notice of transfer, that it was nursing's responsibility, and social services only got involved if nursing was unable to reach the resident's Power of Attorney (POA) or responsible party, The nursing home administrator was made aware of the above concerns related to transfer notification on 10/25/23 at 3:01 PM, When asked who was responsible for notifying the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing when the resident was transferred to the hospital, the NHA indicated he was not sure the facility had a process in place and would let the surveyor know. On 10/26/23 at 10:20 AM, the NHA reported to the surveyor that the facility and Corporate did not have a policy for notifying the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand, and stated that he was getting started on developing a policy. 45139 2) On 10/16/23, a review of Intake #MD00183697 revealed a concern regarding the discharge of Resident #142, a resident admitted to the facility for rehabilitation. On 10/25/23 at 11:24 AM, a review of Resident #142's hospital discharge summary revealed the resident was discharged from the hospital on 9/14/22. On 10/25/23 at 11:35 AM, a review of resident's medical record revealed that Resident #142 was admitted to the hospital. Further review of Resident's #142 medical records revealed that the resident had not returned to the facility, but failed to reveal documentation that the resident was provided notice of discharge and that a discharge summary was documented in the medical record. On 10/25/23 at 12:20 PM, the Director of Nursing reported that she was unable to provide any documentation that Resident #142 had received a discharge notice and that a discharge summary was documented in the resident medical record. On 10/25/23 at 2:59 PM, the Administrator was interviewed. During the interview he reported that he was unsure sure who in his facility was responsible for transfer/discharge documentation. On 10/26/23 at 10:20 PM, the Administrator reported that the facility does not have a transfer/discharge policy and that he had been working on developing one. 48470 3) Resident #96 is a long-term care resident admitted in 2022. On 10/13/23 at 9:35 AM, Resident #96's medical records were reviewed and revealed that the resident was transferred to the hospital in July of 2023. On 10/18/23 at 12:03 PM, the Licensed Practical Nurse (LPN staff#27) was interviewed about the process when a resident is ordered to be transferred to a community hospital for treatment. LPN staff #27 was able to name the different documents and notices that they are required to prepare to facilitate the resident's transfer. The nurse then documents these preparations in the facility's Change in condition/ Concurrent review evaluation form. On 10/19/23 at 1:20 PM, a review of the change in condition/concurrent review form, with a reference date of 7/20/2023 signed by registered nurse (RN staff #46), revealed that section Pwas left unchecked, the area where the nurse would mark the documentation provided to residents or resident representatives for reasons for transfer. There was no evidence found In Resident #96's medical records for this document. On 11/03/23 at 12:30 PM, in an interview with the Director of Nursing (DON staff #2), the concern was discussed that the surveyor found no evidence that the resident or resident representative was notified in writing, regarding the reason for transfer. The exit conference was conducted at 4:15 PM on the same day, and at that time, the facility had not provided documentation to contradict this finding.

Based on observations and interviews, it was determined that the facility failed to provide a home-like environment for residents. This was evident for 2 of 2 nursing units reviewed for the environment. The findings include: On 10/11/23 at 12:16 PM, during a tour of the second-floor unit, an observation was made in room [ROOM NUMBER]B that about a third portion of the paper blinds had been ripped off from the bottom. On 10/12/23 at 1:13 PM, an observation was made of room [ROOM NUMBER], where surveyor observed stained ceiling tiles upon entry to the bathroom. One measured about 4 X4 inches to the right-hand corner of the ceiling and another, 6X6 inches to the left. Further observation was made of a missing ceiling tile, about 18x24 inches, in front of the toilet in the bathroom. A continued observation was made on the second floor on 10/12/23 at 1:16 PM. The observation revealed chipped laminate about 3x2 inches to the left and 1x1 inches to the right sides of the counter at the nurses' station. On 10/11/23 at 9:21 AM, during a tour of the third-floor unit, an observation was made of broken blinds to the window, and five slats of vertical blinds were noted to be missing in room [ROOM NUMBER]A. The overbed table was noted to have rust along the edges of the bottom U-shaped base. The closet door was noted to have scraped edges, and paint was missing along the bottom and around the door handle. On 10/11/23 at 9:49 AM, during a tour of the third-floor unit, an observation was made in room [ROOM NUMBER] of a hole in the left wall upon entry to the room where the interior doorknob hits. The hole measured about 3x3 inches. Further observation on the third-floor unit on 10/11/23 at 11:54 AM revealed a hole to the left side of the wall upon entry to the bathroom in room [ROOM NUMBER], which measured about 2 x1/4 inches. There was also an uncovered recessed night light to the wall under the window, which measured about 9x3 inches. On 10/12/23 at 12:37 PM, an observation of room [ROOM NUMBER] revealed unpainted wood, which measured about 1 x 4 inches to the sides and across the top of the heating, ventilation, and air conditioning system. On 10/12/23 at 12:59 PM, a subsequent observation was made of room [ROOM NUMBER]A, where about a third of the wall to the right-hand corner of the bathroom was unpainted. Upon entry, unpainted and chipped drywall was also observed to the right side of the door. Additionally,a baseboard under the sink was noted with paint peeled off. Further observation was made on 10/12/23 at 1:48 PM, and it showed that room [ROOM NUMBER]-C had a scrape to the left wall upon entry to the room, which measured approximately 12 X 3 inches. The outlet next to the heating, ventilation, and air conditioning system was missing a cover. The drawer unit to the sink in the room had six drawers, with 3 to the right and 3 to the left. The first drawer to the left was missing a drawer pull. The three drawers to the left and one to the bottom right were noted with scrapes, missing paint, and also with exposed fiberboard. There was missing trim to the left side of the drawers. The nightstand was chipped on the front and had a broken door. On 11/3/23 at 10:55 AM, an environmental tour was conducted with staff # 30, Maintenance Assistant. The tour included all of the above findings confirmed by Staff #30. Also, during the tour, an observation was made that there were no handrails between room [ROOM NUMBER] and the double doors. Continued observation on the third floor showed that the third handrail between rooms [ROOM NUMBERS] in the C-Hallway was loose. Another observation was made of a handrail on the left side of the hallway between room [ROOM NUMBER] and the exit door to be loose. Staff # 30 shook the handrails and confirmed they were loose. 11/3/23 at 11:09 AM, during an interview with staff # 30, he confirmed that the concerns that the surveyor brought to his attention were issues. He stated he would report all the concerns through the facility's communication system so the Maintenance Department could begin working on them.

Based on the review of the clinical records, administrative records, observations, and interviews it was determined that the facility failed to implement an effective plan and provide adequate supervision for Resident #1, who was assessed as cognitively impaired and at high risk for elopement. This finding was evident for 1 of 3 residents selected for a review of residents at high risk for elopement. This finding was identified during the investigation of MD 878. An immediate jeopardy was declared on 09-16-2020 at 11:34 AM. The facility submitted an abatement plan at 10:24 PM on 09-16-2020 and it was accepted by the State Agency at 10:53 PM. After removal of the immediacy, the deficiency remained at a potential for more than minimal harm, with a scope and severity of D. The findings include: On 09-14-2020 a review of the facility's policy and procedure for Elopement, which had been approved and in effect as of March 2016, revealed that at the time of admission to the facility, a resident is assessed for wandering and whether a wrist ankle signaling device is warranted. An Elopement Care plan for any resident who has a history of wandering or demonstrates significant behaviors for elopement is also initiated. When a resident demonstrating behaviors of leaving, then staff are to remain with the resident to prevent departure and obtain assistance from other staff members in the immediate vicinity if necessary. If an employee discovers that a resident is missing then a thorough search is to be done of the facility and the premises. If the resident is not located then the administrator and/or the Director of Nursing (DON) is to be notified, as well as the attending physician and local law enforcement when indicated or instructed by the administrator or DON. Also an extensive expanding search pattern of the surrounding area is to be done. Upon the resident's return, the charge nurse will examine the resident for signs of injuries, then notify the attending physician and the legal representative. A incident report is completed and filed, as well as documentation in the resident's record. Additionally, upon return to the facility, the elopement is investigated of how it occurred, as well as identify and implement preventive measures for future elopements. On 09-14-2020 a review of Resident #1's clinical record revealed, on 12-31-2019 the resident scored a six (6) out of 15 on the Brief Interview for Mental Status (BIMS) assessment. A BIMS score of six (6) indicates significant cognitive impairment. On 03-14-2020 at 10:56 AM Licensed Practical Nurse (LPN) #2 completed a wandering/elopement risk assessment on Resident #1. The assessment revealed a total score of 10.0, which indicated that Resident #1 was at risk for wandering. However, there was no documented evidence that a plan of care with interventions to ensure the resident's safety was put into place in response to this risk assessment. A continued review of Resident #1's clinical record revealed a review of a change in condition, documented by LPN #1 on 03-14-2020, revealed that on 03-14-2020, Resident #1 was observed out of his/her room walking in the hallway of the unit and standing in front of the exit door. The resident was then redirected and brought to the nurses' station for close monitoring. The resident was then returned to his/her room, while LPN #1 left to attend to another resident. Intermittent checks were done on the resident, At 4:30 PM the resident was unable to be located in his/her room. Staff members initiated a room to room search within the facility, while a Code purple initiated. Another staff member, including the facility's assigned supervisor, conducted a search outside of the facility's building for the resident. The resident was later observed being assisted back to the facility by a stranger within the community at 4:50 PM on 03-14-2020. Further review of the documentation from Resident#1's 03-14-2020 change in condition revealed, upon the resident's return to the facility, LPN #1 completed a head to toe skin assessment on Resident #1. LPN #1 noted that Resident #1 had abrasions on the knees (bilaterally), and on the right palm. Vital signs were found to be within normal ranges and the resident was placed on one to one (1:1) staff monitoring. On 09-14-2020 Surveyor review a review of LPN #2 nursing documentation, dated 03-15-20-2020 at 2:30 PM revealed, Resident #1 remained on 1:1 monitoring. Subsequent documentation dated 03-16-2020, by the second floor Unit Manager (UM) revealed that elopement protocols were put into place post Resident #2's elopement incident that included a (one to one) monitoring until a Wanderguard becomes available. A Wanderguard is an alarm system used in wandering or elopement management. The system usually involve some type of antenna system connected to a controller and a door contact switch. Residents who are at risk wear a wrist or ankle transmitter, when if the transmitter comes in contact close to the door that is protected by this type of system, the antenna singles out the transmitter of the resident. However, on 09-14-2020 surveyor record review revealed no evidence that a Wanderguard placement order was put into place until 03-17-2020 for Resident #1. In addition, there was no evidence of a physician order [REDACTED]. On 09-14-2020 a review of Resident #1's September 2020 Treatment Administration Record (TAR) revealed LPN #6 had documented that the resident's Wanderguard was in place during the shift (Refer to F842 for additional information) On 09-14-2020 at 1:30 PM and 5:30 PM the surveyor's observations of Resident #1 revealed no evidence of a Wanderguard in place on the resident's upper or lower extremities. Surveyor interview on 09-14-2020 at 5:10 PM with Human Resources (HR) director revealed that she had worked at the front reception desk on 03-14-2020. The HR director stated that the receptionist's duties included covering the main entrance of the facility, where the receptionist presses a button, located at the desk, to allow entry and exit from the entrance. In addition, when the receptionist is not at the desk, then a keypad door code is required for entry and/or exit from the main entrance door. The receptionist is stationed at the main entrance desk of the facility from 8:00 AM-8:00 PM daily. Further interview with the HR director revealed that on 03-14-2020 a 3:00-11:00 staff member had notified her that Resident #1 was unable to be located by staff within the facility, and that staff members were going to drive around in the community to try to locate the resident. Sometime after staff had left the facility, the resident was observed being escorted back to the facility by a male individual from the community, who stated that he had seen the resident wandering miles from the facility. Upon the resident's return, RN #4 had returned also to the facility after driving around in an attempt to locate the resident. The HR director recalled that there had been no contact made to the local law enforcement by the facility at the time the resident was missing. On 09-14-2020 at 6:06 PM interview with Geriatric Nursing Assistant (GNA) #3 revealed that on 03-14-2020 around 4:00 PM or 4:30 PM Resident #1 had been observed by GNA #3 nearing the elevator on the unit and also nearing the stairwell door on the unit's A wing. GNA #3 proceeded to redirect the resident back to his/her room as well as to the nurse's station. GNA #3 further stated that he had placed a chair in front of the stairwell door in order to deter the resident from the door. When asked if the stairwell door was locked and operational only with a keypad code, GNA #3 stated that the door was locked, but had recalled problems with the locking mechanism in the past. However, he was unable to recall the last time there was an issue with the door's locking mechanism. Further interview with GNA #3 revealed that after 4:30 PM the resident was unable to be located within the unit and efforts went unsuccessful to locate the resident throughout the facility. GNA #3 then drove around the facility area to locate the resident, and upon returning to the facility, saw the resident being escorted back to the front of the facility by a gentleman from the community. Staff then escorted the resident back to the unit where both the supervisor and LPN #2 assessed the resident. The resident was monitored by staff frequently during the rest of the shift. However, surveyor interview on 09-14-2020 at 5:00 PM and 09-15-2020 at 2:00 PM with the Administrator and the Director of Nursing revealed no evidence that the 03-14-2020 elopement of Resident #1 had been reported to the Office of Health Care Quality (OHCQ). In addition, further interview revealed no evidence of a thorough investigation of the elopement was documented. Evidence of an investigation into the events of Resident#1's elopement was not provided to the surveyor upon request. (Refer to F609 and F610 for additional information). Surveyor interviews conducted from 09-14-2020 and 09-15-2020 with facility staff members revealed no cohesive response in what the facility's elopement policy had been put into place. On 09-15-2020 at 11:00 AM interview with the Second Floor Unit Manager revealed that documentation on 03-26-2020 revealed that Resident #1 was moved from a room on the second floor to a room on the third floor due to better room arrangement. The Second Floor Unit Manager stated that the room on the third floor was more secured. However, follow up with the Director of Nursing on 09-15-2020 at 10:30 AM revealed that the A wing unit on the third floor was not secured with a keypad code for entry and exit accessibility until two weeks ago. Interview 09-15-2020 at 11:12 AM with the maintenance director revealed that after the 03-14-2020 elopement incident of Resident #1 that he and the previous administrator had reviewed the facility's camera systems to determine how the resident had eloped, but no visual information was obtained from the cameras. Further interview revealed that the Wanderguards were available for staff to obtain. Interview on 09-15-2020 at 11:19 AM with the Assistant Director of Nursing (ADON) recalled that he and Registered Nurse (RN) #4 had initiated an investigation into the 03-14-2020 elopement of Resident #1. The investigation's documentation was then forwarded to the interim DON at that time and the former administrator. The ADON stated that he had walked around the building to check for possible exits that may have been used by the resident to elope, and found that the resident would have had difficulty in leaving the unit from the stairwell due to the keypad code need as well as the difficulty for the resident in accessing the loading dock exit located behind the facility. However, there was no documented evidence that a thorough investigation of the elopement was completed so that the facility could determine contributing factors and take action to implement systematic changes to prevent a similar incident from reoccurring. Despite surveyor request the facility did not provide documented evidence of an investigation of resident #1's elopement during the 2 week survey. Surveyor interview on 09-15-2020 at 12:48 PM with Licensed Practical Nurse (LPN) #2 revealed that initially when first admitted resident #1 was weak and needed total assistance and under Hospice care. The resident became stronger and able to ambulate more without assistive device. Further interview revealed that during the 7-3 shift on 03-14-2020 the resident was observed with exit seeking behaviors that included having his/her jacket on and wanting to leave. The resident's spouse would initially come daily to visit but due to COVID restrictions, no visitors were allowed within the facility. LPN #2 stated that the resident was redirected during the shift and a wandering/elopement risk assessment was completed due to the resident's behavior. The outcome of the risk assessment indicated that the resident was at risk to wander. However, LPN #2 stated that other than checking on resident frequently during the shift there was no documentation of any other interventions put into effect now that the resident was now indicated to be at risk to wander and no further at low risk to wander. LPN #2 further stated that she did inform the incoming 3:00-11:00 nurse (LPN #1) of the resident's exit seeking behavior on this day. On 09-15-2020 at 1:23 PM surveyor interview with RN #4 revealed that on 03-14-2020 she was the supervisor on duty for the facility and was notified by LPN #1 that resident #1 could not be located on the unit. RN #4 as well as another staff member went to drive around the area to look for the resident and later saw the resident being escorted back into the lobby by a gentleman from the community. The gentleman stated that the resident had an activity sheet with the name of the facility on it. Upon assessment with LPN #1 there were abrasions noted and the resident was placed on 1:1 monitoring with 15 minute checks. RN #4 recalled that the ADON and she had completed a risk management document with the information on the 24 hour report. When asked if the elopement was reported to OHCQ by RN #4 or the ADON, RN #4 responded that the, responsibility in reporting is not hers. Interview with Resident #1's representative on 09-15-2020 at 4:36 PM revealed the facility had initially notified the representative when the resident had returned to the facility by a person in the community after being found wandering around with no shoes on. Further interview revealed that a staff member told the representative that Resident #1 sustained a few scratches and the facility did not know how the resident got out of the facility, maybe from the back of the facility. They further stated to the representative that this the facility would implement 10 minute checks for Resident #1, and move the resident to a room on the third floor. The representative was adamant there was never any contact received from the facility at the time the resident went missing, but only after the resident was returned to the facility. The facility failed to ensure the safety of resident #1, who was assessed as cognitively impaired and at high risk for elopement. In addition, the facility had failed to document a thorough investigation into the events around the 03-14-2020 elopement and implement systematic changes to prevent a similar incident from reoccurring with residents cognitively impaired and at high risk for elopement. Therefore, immediate action was needed to ensure resident's safety and supervision who are assessed at risk for wandering and/or elopement.As a result of these findings an immediate jeopardy was declared on 09-16-2020 at 11:34 AM. The facility submitted an abatement plan at 10:24 PM that was accepted by the State Agency at 10:53 PM. The provisions of the plan to remove the immediacy included the following: 1. Resident # 1 returned to the facility on the afternoon of 3/14/20 at approximately 5:00 PM and placed on 1:1 observation. A Wanderguard was placed on 03-17-2020 and the 1:1 was removed. On 09-14-2020 the resident was observed without a Wanderguard by the surveyor. Another Wanderguard was tested and placed by DON on 09-14-2020. LPN #6 was educated and disciplined by the DON re: falsification of records; documentation of placement and functionality. Care plan for resident #1 was revised 09-16-2020 by the Unit Manager. Compliance 09-25-2020. 2. Elopement policy was revised on 09-15-2020 by the Administrator. Revisions included frequency of elopement risk assessment, proper code announcement, and investigation measures to be taken by Supervisor managing the elopement. Nursing Protocol for elopement prevention for residents at risk for elopement was developed by DON on 09-16-2020. Unit Managers' Job Descriptions were amended by DON on 09-16-2020 to include Supervision of all nursing functions in the absence of the DON. Compliance 09-25-2020. 3. 100% current facility residents were assessed by DON for elopement risk on 09-14-2020 to 09-16-2020. Six (6) residents were identified to be at high risk. Elopement prevention binder was audited for accuracy and completion by DON on 09-14-2020. All residents at high risk for elopement had their Wanderguard bracelets verified for placement and functionality on 09-14-2020. Newly assessed high Risk residents were added to the elopement binder by the DON on 09-14-2020. Reception desk photo board updated with photos of residents at High Risk for elopement by Activities Director on 09-16-2020. Care plans for residents at risk for elopement were reviewed and updated by Unit Managers between 09-16-2020 and 09-22-2020. Compliance 09-25-2020. 4. Administrator designated unit 3A to be established as a secured unit for residents at risk of elopement on 09-02-2020. Residents at risk were transferred to the 3A unit on 09-15-2020. Compliance 09-25-2020. 5. On 09-14-2020, Maintenance Director inspected all security doors (stairwells, exit doors, doors to entrance of 3A unit) for proper closure, locking, Wanderguard alarm sounding and coded operation. All were found to be functioning properly. Check for items blocking door was made, and no items blocking exit were noted. Item propping open the A stairwell door to the maintenance shop was removed. The codes for mag lock release for stairwells and exterior exit doors were changed by Maintenance Director on 09-15-2020 and 09-16-2020. Compliance 09-25-2020. 6. a. Staff of all departments will be educated by Administrator, Director of Nursing, and Nursing Supervisor regarding the revised elopement policy and investigation procedures. Licensed staff members educated by Director of Nursing regarding proper placement, proper functioning, frequency of testing, and proper documentation, Staff of all Departments will be educated by Staff Educator, DON and Administrator on the a) Nursing protocol for Elopement prevention b) Identifying and reporting likely signs of elopement, c) Exit seeking behavior, and d) The potential harm to residents as a result of elopement b. Administrator will educate department heads and supervisors on Facility Reported Incidents - definitions, format, process, requirements and mandatory reporters. c. In-service education was provided to nurse managers by Maintenance Director regarding use of Wanderguard tester (testing of Wanderguard bracelet function), keeping exit doors clear of any blocking items to ensure safe egress / escape. d. Receptionists and Human Resources Director will be trained by Administrator and DON to compare all persons exiting the front door with photo board pictures of high risk residents prior to exiting and, to inform supervisor / nursing management if a high risk resident who presents at the front desk. e. At the completion date, no staff member will be permitted to work their shift until education as stipulated above, has been completed. Compliance 09-25-2020. 7. Elopement drills will be conducted by Administrator, bimonthly x 3 months (1 per shift x 2) and then quarterly for 3 quarters (alternating shifts) to ensure that staff are properly a) alerted, b) perform the security search as required, c) make the appropriate notifications, d) identify the route of elopement, and e) prepare after-action root cause analysis / post drill investigation. Compliance 09-25-2020. 8. Weekly x 13 weeks, Director of Nursing will audit to ensure residents triggering for elopement risk are: a. care planned b. included in the elopement binder c. photo added to photo board d. wander guard bracelets placed and functioning properly e. MAR / TAR documentation is accurate and complete. Compliance 09-25-2020. 9. Daily, for 13 weeks, Director of Maintenance and/or Nursing Supervisor will conduct security door (stairwells, exit doors, and entrance to the 3A unit) to ensure a. doors close properly b. Mag locks engage properly c. wander guard alarms sound properly d. door is not blocked by any objects e. doors are not propped open Compliance 09-25-2020. 10. Weekly x 13 weeks, then quarterly for 3 quarters, Human Resources Director will monitor the receptionists (alternating receptionists) to ensure receptionists are comparing residents exiting with photo board., and in the event a resident identified as a high risk for elopement is observed, is reported to the Supervisor / Nurse management on duty. Compliance 09-25-2020. 11. Monthly x 3 months, a random 25% sample of staff will be evaluated by Administrator and Staff Development Coordinator regarding their knowledge / competency of: a. elopement policies and protocols b. security door safety Compliance 09-25-2020. 12. Monthly, for the duration specified, the results of the a) Elopement drills, b) DON elopement Audits, c) Security door audits, d) reception audits and e) employee knowledge and competencies will be submitted to the Quality Assurance/Performance Improvement Committee for review. QAPI committee will determine if the plans are effective or will implement corrective changes to the plan. Compliance 09-25-2020. The immediate jeopardy was removed on 09-28-2020 at 5:05 PM. On 09-14-2020 a review of the facility's policy and procedure for Elopement, which had been approved and in effect as of March 2016, revealed that at the time of admission to the facility, a resident is assessed for wandering and whether a wrist ankle signaling device is warranted. An Elopement Care plan for any resident who has a history of wandering or demonstrates significant behaviors for elopement is also initiated. When a resident demonstrating behaviors of leaving, then staff are to remain with the resident to prevent departure and obtain assistance from other staff members in the immediate vicinity if necessary. If an employee discovers that a resident is missing then a thorough search is to be done of the facility and the premises. If the resident is not located then the administrator and/or the Director of Nursing (DON) is to be notified, as well as the attending physician and local law enforcement when indicated or instructed by the administrator or DON. Also an extensive expanding search pattern of the surrounding area is to be done. Upon the resident's return, the charge nurse will examine the resident for signs of injuries, then notify the attending physician and the legal representative. A incident report is completed and filed, as well as documentation in the resident's record. Additionally, upon return to the facility, the elopement is investigated of how it occurred, as well as identify and implement preventive measures for future elopements. On 09-14-2020 a review of Resident #1's clinical record revealed, on 12-31-2019 the resident scored a six (6) out of 15 on the Brief Interview for Mental Status (BIMS) assessment. A BIMS score of six (6) indicates significant cognitive impairment. On 03-14-2020 at 10:56 AM Licensed Practical Nurse (LPN) #2 completed a wandering/elopement risk assessment on Resident #1. The assessment revealed a total score of 10.0, which indicated that Resident #1 was at risk for wandering. However, there was no documented evidence that a plan of care with interventions to ensure the resident's safety was put into place in response to this risk assessment. A continued review of Resident #1's clinical record revealed a review of a change in condition, documented by LPN #1 on 03-14-2020, revealed that on 03-14-2020, Resident #1 was observed out of his/her room walking in the hallway of the unit and standing in front of the exit door. The resident was then redirected and brought to the nurses' station for close monitoring. The resident was then returned to his/her room, while LPN #1 left to attend to another resident. Intermittent checks were done on the resident, At 4:30 PM the resident was unable to be located in his/her room. Staff members initiated a room to room search within the facility, while a Code purple initiated. Another staff member, including the facility's assigned supervisor, conducted a search outside of the facility's building for the resident. The resident was later observed being assisted back to the facility by a stranger within the community at 4:50 PM on 03-14-2020. Further review of the documentation from Resident#1's 03-14-2020 change in condition revealed, upon the resident's return to the facility, LPN #1 completed a head to toe skin assessment on Resident #1. LPN #1 noted that Resident #1 had abrasions on the knees (bilaterally), and on the right palm. Vital signs were found to be within normal ranges and the resident was placed on one to one (1:1) staff monitoring. On 09-14-2020 Surveyor review a review of LPN #2 nursing documentation, dated 03-15-20-2020 at 2:30 PM revealed, Resident #1 remained on 1:1 monitoring. Subsequent documentation dated 03-16-2020, by the second floor Unit Manager (UM) revealed that elopement protocols were put into place post Resident #2's elopement incident that included a (one to one) monitoring until a wander guard becomes available. A wander guard is an alarm system used in wandering or elopement management. The system usually involve some type of antenna system connected to a controller and a door contact switch. Residents who are at risk wear a wrist or ankle transmitter, when if the transmitter comes in contact close to the door that is protected by this type of system, the antenna singles out the transmitter of the resident. However, on 09-14-2020 surveyor record review revealed no evidence that a Wander guard placement order was put into place until 03-17-2020 for Resident #1. In addition, there was no evidence of a physician order [REDACTED]. On 09-14-2020 a review of Resident #1's September 2020 Treatment Administration Record (TAR) revealed LPN #6 had documented that the resident's Wander guard was in place during the shift (Refer to F842 for additional information) On 09-14-2020 at 1:30 PM and 5:30 PM the surveyor's observations of Resident #1 revealed no evidence of a wander guard in place on the resident's upper or lower extremities. Surveyor interview on 09-14-2020 at 5:10 PM with Human Resources (HR) director revealed that she had worked at the front reception desk on 03-14-2020. The HR director stated that the receptionist's duties included covering the main entrance of the facility, where the receptionist presses a button, located at the desk, to allow entry and exit from the entrance. In addition, when the receptionist is not at the desk, then a keypad door code is required for entry and/or exit from the main entrance door. The receptionist is stationed at the main entrance desk of the facility from 8:00 AM-8:00 PM daily. Further interview with the HR director revealed that on 03-14-2020 a 3:00-11:00 staff member had notified her that Resident #1 was unable to be located by staff within the facility, and that staff members were going to drive around in the community to try to locate the resident. Sometime after staff had left the facility, the resident was observed being escorted back to the facility by a male individual from the community, who stated that he had seen the resident wandering miles from the facility. Upon the resident's return, RN #4 had returned also to the facility after driving around in an attempt to locate the resident. The HR director recalled that there had been no contact made to the local law enforcement by the facility at the time the resident was missing. On 09-14-2020 at 6:06 PM interview with Geriatric Nursing Assistant (GNA) #3 revealed that on 03-14-2020 around 4:00 PM or 4:30 PM Resident #1 had been observed by GNA #3 nearing the elevator on the unit and also nearing the stairwell door on the unit's A wing. GNA #3 proceeded to redirect the resident back to his/her room as well as to the nurse's station. GNA #3 further stated that he had placed a chair in front of the stairwell door in order to deter the resident from the door. When asked if the stairwell door was locked and operational only with a keypad code, GNA #3 stated that the door was locked, but had recalled problems with the locking mechanism in the past. However, he was unable to recall the last time there was an issue with the door's locking mechanism. Further interview with GNA #3 revealed that after 4:30 PM the resident was unable to be located within the unit and efforts went unsuccessful to locate the resident throughout the facility. GNA #3 then drove around the facility area to locate the resident, and upon returning to the facility, saw the resident being escorted back to the front of the facility by a gentleman from the community. Staff then escorted the resident back to the unit where both the supervisor and LPN #2 assessed the resident. The resident was monitored by staff frequently during the rest of the shift. However, surveyor interview on 09-14-2020 at 5:00 PM and 09-15-2020 at 2:00 PM with the Administrator and the Director of Nursing revealed no evidence that the 03-14-2020 elopement of Resident #1 had been reported to the Office of Health Care Quality (OHCQ). In addition, further interview revealed no evidence of a thorough investigation of the elopement was documented. Evidence of an investigation into the events of Resident#1's elopement was not provided to the surveyor upon request. (Refer to F609 and F610 for additional information). Surveyor interviews conducted from 09-14-2020 and 09-15-2020 with facility staff members revealed no cohesive response in what the facility's elopement policy had been put into place. On 09-15-2020 at 11:00 AM interview with the Second Floor Unit Manager revealed that documentation on 03-26-2020 revealed that Resident #1 was moved from a room on the second floor to a room on the third floor due to better room arrangement. The Second Floor Unit Manager stated that the room on the third floor was more secured. However, follow up with the Director of Nursing on 09-15-2020 at 10:30 AM revealed that the A wing unit on the third floor was not secured with a keypad code for entry and exit accessibility until two weeks ago. Interview 09-15-2020 at 11:12 AM with the maintenance director revealed that after the 03-14-2020 elopement incident of Resident #1 that he and the previous administrator had reviewed the facility's camera systems to determine how the resident had eloped, but no visual information was obtained from the cameras. Further interview revealed that the Wander guards were available for staff to obtain. Interview on 09-15-2020 at 11:19 AM with the Assistant Director of Nursing (ADON) recalled that he and Registered Nurse (RN) #4 had initiated an investigation into the 03-14-2020 elopement of Resident #1. The investigation's documentation was then forwarded to the interim DON at that time and the former administrator. The ADON stated that he had walked around the building to check for possible exits that may have been used by the resident to elope, and found that the resident would have had difficulty in leaving the unit from the stairwell due to the keypad code need as well as the difficulty for the resident in accessing the loading dock exit located behind the facility. However, there was no documented evidence that a thorough investigation of the elopement was completed so that the facility could determine contributing factors and take action to implement systematic changes to prevent a similar incident from reoccurring. Despite surveyor request the facility did not provide documented evidence of an investigation of resident #1's elopement during the 2 week survey. Surveyor interview on 09-15-2020 at 12:48 PM with Licensed Practical Nurse (LPN) #2 revealed that initially when first admitted resident #1 was weak and needed total assistance and under Hospice care. The resident became stronger and able to ambulate more