Every finding on record at Autumn Lake Healthcare at Pikesville

Based on interviews, review of resident records and review of pertinent documentation, the facility failed to provide quarterly statements of the resident's funds or maintain a complete and separate accounting of a resident's personal funds by failing to maintain financial records that could be reconciled or substantiated. This was evident for 1 (Resident #13) of 1 residents reviewed for resident funds and affected all residents with a resident funds account. The findings include:1) On 7/27/26 at 1:42 PM, in an interview with Resident #13's responsible party (RP), she stated that the facility takes care of the resident's money. During the interview the RP stated the resident had not received any money since approximately March/April 2025. When asked if they received quarterly statements from the facility, the RP stated, I have never received one.On 7/29/26 at 12:32 PM in an interview with the Nursing Home Administrator (NHA) when asked who the Business Office Manager (BOM) was for the facility, he stated it was himself and the Admissions Department on site and an external consultant offsite.On 7/29/26 at 1:37 PM in an interview with the Nursing Home Administrator (NHA), when asked how many resident fund accounts were managed by the facility, he provided a copy of the RFMS (Resident Fund Management System) Trial Balance (3 pages of resident fund balances as of 7/29/26) and stated 98 residents. On 7/29/26 at 2:16 PM, in an interview with the Nursing Home Administrator (NHA), when asked if residents were provided with statements, he stated that residents were provided with financial statements on a quarterly basis. The NHA stated if residents were their own RP, they would sign for and receive their statements directly and if they were not their own RP, the statements were mailed to their RPs. When asked what documentation existed to support that these statements were provided to the residents and RPs, the NHA stated that the facility maintained a book that documented when quarterly statements were mailed to RPs and the quarterly statements with the residents' signatures who were their own RP. On 7/29/26 at 2:50 PM, the NHA provided a binder to the surveyor containing what he identified as quarterly statements for all residents spanning the 2025 calendar year. When the surveyor asked about the quarterly statements for 2026, the NHA stated that no quarterly statements had been generated or distributed for 2026. In an attempt to clarify, when asked, not one resident/RP had been provided a quarterly statement for 2026, he stated, No, but we'll work on getting them sent out. On 7/30/26 at 9:01 AM after surveyor intervention, the NHA provided a binder labeled 2026 and said these were the 2nd quarter statements of 2026 for the residents. When asked about 1st quarter statements for 2026, he said there were none. The surveyor shared this was a concern. The NHA acknowledged understanding of the concern and offered no further comment at that time.On 7/30/26 at 10: 43 AM review of the facility policy, Transactions Involving Resident Funds, revealed, Quarterly statements will be provided in writing to the resident, or the resident's representative, within 30 days after the end of the quarter and upon request. 2) On 7/27/26 at 1:49 PM review of Resident #13's medical record revealed he/she was originally admitted to the facility in April 2022 and was a Medicaid recipient.On 7/28/26 at 1:25 PM the surveyor requested Resident #13's resident funds statements from April 2025 to present. On 7/29/26 at 11:01 AM, in an interview with the Nursing Home Administrator (NHA) he stated Resident #13 transferred from another facility that was the rep payee and that they had been attempting to become rep payee since the resident's admission. When asked who was paying the resident's contribution of care, the NHA provided no comment at that time. The surveyor requested the resident's current Medicaid Notice of Eligibility ([NAME]). During the interview the NHA provided the previously requested resident fund statements for Resident #13. Review of the resident fund statements from April 2025 through the survey period reflected no deposits of the resident's Personal Needs Allowance (PNA) and a balance that did not exceed $3.28 on any of the quarterly statements.On 7/29/26 at 1:37 PM, the NHA provided a Resident Funds Management System (RFMS) Trial Balance dated 7/29/26. The documentation for Resident #13 reflected a current balance of $3.28, a pending balance of $3.28, and an allowance of $109. However, the resident fund statements provided by the facility did not reflect deposits or accumulated balances consistent with the documented allowance.On 7/29/26 at 1:40 PM the NHA provided a Long Term Care Change dated 2/15/19. In an interview with the NHA when asked if this was the most recent documentation, he stated he would check.On 7/29/26 at 2:59 PM in an interview with the NHA when asked about Resident #13's most recent Medicaid [NAME], the NHA stated the facility did not have one because the resident was receiving SSI. When asked why the resident's quarterly statements failed to reflect any deposits or withdrawals, the NHA stated the previous facility remained rep payee. On 7/30/26 at 11:50 AM in an interview with the Admissions Liaison/former Admissions Director, she stated Resident #13 was not receiving SSI, had no income, and that the facility and resident's daughter had been attempting to initiate benefits and rep payee status. When asked where the resident's SSI benefits were going and who was paying his/her contribution of care, she stated, He/she's not receiving any SSI. He/she doesn't have any income. The daughter and one of our specialists from [the external consultant company's name] did the application to start getting his/her benefits and to become the rep payee. I don't know if [the external consultant company's name] is appointing for the daughter or [the external consultant company's name] to become the rep payee, but they assisted the daughter with doing the application. When asked why this had not been resolved after more than four years, she stated, I can't speak to that.On 7/30/26 at 1:10 PM in an interview with the NHA, he stated Resident #13 was receiving SSI and that the resident's care was being paid by Medicaid. When informed that the RFMS Trial Balance reflected a $109 allowance while the resident fund statements reflected no deposits, the NHA stated only that the facility had been trying to become the rep payee. On 7/31/26 at 10:30 AM in an interview with the Admissions Liaison/former Admissions Director she reported the external financial consultant was attempting to determine why the RFMS system reflected a $109 PNA. When asked where those funds were, she offered no explanation. She later stated the $109 allowance may have been an error generated by the external contractor's software and that the resident actually should have had a $30 allowance. She further stated the previous rep payee (the previous facility) reportedly received the resident's monthly allowance until 8/16/23, after which payments stopped and said, It's probably all backed up in Social Security. She could not explain why no $30 deposits appeared on the resident's quarterly statements.On 7/31/26 at 11:45 AM in an interview with Resident #13's daughter, she stated her mother had been receiving monthly SSI benefits, and she was the rep payee. Then, her mother was admitted to the previous facility and that she did give them the right to become rep payee. During the interview she said that her mother was getting about $30 a month that went into a separate account to be able to buy things like cigarettes, but the resident stopped receiving those funds in approximately March 2025. She further stated she only learned her mother no longer had available funds after requesting the facility purchase cigarettes using the resident's personal account and was told there was no money available.Record review demonstrated the resident fund statements for Resident #13 maintained by the facility reflected virtually no deposits and a balance that remained at or below $3.28 throughout the review period, despite the facility's RFMS Trial Balance documenting a resident allowance. Despite repeated requests throughout the survey, the facility was unable to produce documentation to reconcile the RFMS Trial Balance allowance with the resident fund statements or explain the basis for the resident allowance reflected in its accounting records. At no time during the survey did the facility produce documentation identifying the source of the resident allowance reflected in its RFMS Trial Balance, accounting for its disposition, or reconciling the RFMS Trial Balance with the resident fund statements maintained for Resident #13.Although facility staff stated another entity remained the representative payee, the facility nevertheless maintained Resident #13 within its RFMS, generated quarterly resident fund statements, maintained a Trial Balance reflecting a resident allowance, and maintained these documents as part of its resident funds accounting records. Facility staff acknowledged the RFMS Trial Balance was generated from the facility's resident funds management system but were unable to provide documentation supporting the allowance reflected therein, reconcile the Trial Balance allowance with the resident fund statements, explain the discrepancies between those records, or otherwise substantiate the balances reflected in the facility's accounting records despite repeated requests during the survey.

Based on observation and interview it was determined that the facility failed to maintain proper procedures for food safety by storing food properly, maintaining a clean kitchen area and serve food at the proper temperature. This was evident during the two tours of the kitchen and staff interviews.The findings include:1a. During the initial tour of the kitchen on 07/27/2026 9:07 AM the floor in the kitchen was dirty, covered with debris and sticky to the point that the surveyor's shoes were sticking to the floor. During the initial tour the state of the floors was brought to the attention of the Administrator, and the Kitchen Manager was asked when the floors were last mopped, and she stated that the Housekeeping Department cleaned the floors once a month but the last time they were there they did half of it and stated they would return. On 7/27/2026 at 10:35 AM , the Maintenance Director was interviewed and asked about the floor cleaning schedule. He stated that the Housekeeping Department cleaned the floor once a month with the Autoclean machine on the 15th, but they were unable to get to the kitchen floor in July 2026 so they last time it was deep cleaned was June 15, 2026. He also stated that the kitchen staff was responsible for the daily cleaning of the kitchen floor. At 12:05 PM on 07/27/206, the Regional Dietary Manager stated that the kitchen floors were mopped after each meal. This was not evidenced by the state of the floors and the statement of the Kitchen Manager.1b. Further observation in the tray service area, revealed peeling paint and an extremely rusted pipe next to the steam/food service table.1c. During the initial tour on 7/27/2026 at 9:07 AM, in the refrigerator, a box of sausage links was observed in an open box with an open plastic bag, exposing the sausage to the air. The Kitchen Manager witnessed the opened sausage and disposed of them.1d. During a second tour of the kitchen, on 7/28/2026 at 11:15 AM, it was observed that 2 trays of broccoli were in the freezer completely uncovered and a pan of tuna fish salad was partially uncovered. The Kitchen Manager stated that the tuna fish salad and the broccoli had been put in the freezer to cool.1e. On 7/28/2026 at 12:30 PM, during an observation of the tray line, it was observed that the employee putting the food on the plates had failed to take the temperature of the food on the serving table and did not do so until asked by the surveyor. The temperature of the cold pureed broccoli salad was then discovered to be 52 degrees (cold food should be served at 42 degrees or lower). The Kitchen Manager immediately removed the item from the tray line.1f. A test tray was requested and delivered to the conference room by the Kitchen Manager. The surveyor had the Kitchen Manager take the temperature of the food on the tray. The cold Pea Salad's temperature was 48 degrees

Based on observations and staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was found to be evident in the 2nd floor shower room, resident rooms #213 and #229, and in Rooms #119, #126, 129, 130, and 227 during the recertification survey. The findings include: 1) On 7/27/2026 at 8:58 AM, a tour of the second-floor shower room revealed water collected in the shower bed pan, substantial splintering of wood on the lower half of the shower room entrance door, and full trash bags touching a shower curtain. An additional tour of the second-floor shower room on 07/28/26 at 8:40 AM revealed substantially sized holes (8 inches to 10 inches in diameter) at 3 of the 4 light fixtures on the ceiling. 2) On 07/27/26 at 9:15 AM, the surveyor inspected room [ROOM NUMBER] and observed a hole measuring approximately 12 inches in diameter at the baseboard and several areas of stripped paint on the wall directly behind the head of the resident's bed. Inspection of room [ROOM NUMBER] at 9:17 AM revealed multiple areas of dry wall repair filler unpainted throughout the room and adjoining bathroom, a hole and cracked paint near the rooms' packaged terminal air conditioner, stripped paint and multiple scratches on the wall directly behind the head of bed B, and a warped ceiling panel above the residents' closets. 3) On 07/27/2026 from 8:00 AM through 9:30 AM, observations made during resident interviews revealed damaged drywall in multiple resident rooms. room [ROOM NUMBER] had damaged drywall. room [ROOM NUMBER] had damaged drywall. room [ROOM NUMBER] had damaged dresser drawers and damaged drywall behind the bed. room [ROOM NUMBER] had damaged drywall behind the bed. At 8:12 AM, room [ROOM NUMBER] was observed to have a leaking air conditioning unit with damaged drywall surrounding the unit. An interview was held on 7/29/2026 at 11:00 AM with the Nursing Home Administrator who was made aware of environmental concerns and stated they would have them addressed. The Nursing Home Administrator acknowledged the identified repair needs and stated that the leaking air conditioning unit and wall damage in room [ROOM NUMBER] was already in the process of being repaired.

Based on interview with facility staff and review of pertinent documentation, the facility failed to ensure that residents, who received Medicaid benefits, and/or their responsible party (RP) were notified when the amount in the resident's account reached $200 less than the Supplemental Security Income (SSI) resource limit. Additionally, the facility failed to provide the required notification that if the resident's account balance, together with other nonexempt resources, reached the SSI resource limit, the resident could lose Medicaid or SSI eligibility. This was found to be evident for 10 (Residents #34, #37, #38, #50, #56, #61, #71, #80, #82, #9) of 10 residents reviewed with a resident funds account that reached $200 less than the SSI limit.The findings include:On 7/29/26 at 12:32 PM in an interview with the Nursing Home Administrator (NHA) when asked who the Business Office Manager (BOM) was for the facility, he stated it was himself and the Admissions Department on site and an external consultant offsite.On 7/29/26 at 1:40 PM review of the RFMS (Resident Fund Management System) Trial Balance (3 pages of resident fund balances as of 7/29/26 ) for the facility revealed 10 residents (Residents #34, #37, #38, #50, #56, #61, #71, #80, #82, #9) whose accounts reached $200 below the SSI resource limit and 9 residents (Residents #34, #37, #38, #50, #61, #71, #80, #82, #9) whose accounts had reached the SSI resource limit, placing them at risk of losing Medicaid or SSI eligibility. Review of the RFMS Trial Balance dated 7/29/26 showed 10 residents remained at or above the notification threshold. The facility produced notification letters dated April 23, 2026, but was unable to provide evidence that all affected residents/RPs had been notified in accordance with regulatory requirements. Review of the April 23, 2026, Resident Fund Balance Notification letters provided showed the letters advised residents to contact the social worker regarding continuation of Medicaid benefits; however, the letters did not include notification that if the amount in the resident's account, together with other nonexempt resources, reached the SSI resource limit, the resident may lose eligibility for Medicaid or SSI, as required by regulation.On 7/30/26 at 12:02 PM in an interview with the NHA when asked who was responsible for monitoring resident fund account balances and ensuring required notifications were provided, he stated that he and the Activities Department were responsible. During the interview he stated, A Medicaid specialist from [the external consultant's company name] notifies us that so and so has, for example, $2700 in their account. The surveyor shared the concern that there were 10 residents whose account balance had reached the notification threshold ($200 less than the SSI resource limit) and 9 residents that were at or above the SSI resource limit who may be at risk of losing their Medicaid or SSI benefits. The NHA acknowledged the concerns but offered no further comment at that time.On 7/30/26 at 2:47 PM in an interview with the NHA when asked if the facility notified Medicaid residents/RPs when the resident's account reached $200 below the SSI resource limit and that if the amount in the account reached the SSI limit, that the resident/RP was also notified, that they may lose eligibility for Medicaid or SSI, he stated, yes. When asked about the notification process, he stated, I do that. I send them a letter. During the interview when asked what evidence he could provide to show the residents/RPs were notified, he stated the letters. The surveyor requested evidence of those notifications.On 7/31/26 at 8:44 AM in an interview with the NHA he provided letters titled, Resident Fund Balance Notification all dated April 23, 2026, and stated, Here's the notification letters for the residents. Some of them we're still working on. When asked how a surveyor would be able to verify that the letters were provided, he stated, For the residents that can and are their own RP, they sign and for those who can't we email it to their RP. Review of the 4/23/26 Resident Fund Balance Notification letters revealed a letter for Residents #37, #38, #56, #71, and #9; however, the NHA did not provide any evidence that the letter had been sent to the RP. Further review of the documents revealed a notification letter for Residents #50 and #61 and evidence of the letter being signed by Resident #50 and the letter being sent to the RP of Resident #61; however, the regulation states that the facility must notify the resident when the account balance reaches the notification threshold ($200 less than the SSI resource limit). Although notification letters dated April 23, 2026, were produced for Residents #50 and #61, the facility did not provide additional documentation demonstrating compliance with the notification requirements after April 23, 2026. Additionally, the notification letters did not include the required notice that if the amount in the resident's account, together with other nonexempt resources, reached the SSI resource limit, the resident could lose Medicaid or SSI eligibility. Finally, the NHA did not provide any copy of a notification letter or evidence of notification being provided to the resident/RP for Residents #34, #80 or #82.On 7/31/26 at 9:26 AM in an interview with the NHA when asked how often notification letters were provided/sent out, he stated, Whenever they reach within the $200 limit. We try not to meet the $200 limit, but when it gets to the limit, we send the notification letters. When asked to clarify, the NHA stated, We continue to reach out if they reach the limit, but no, another letter is not sent out. When asked if there was a certain number of times a year a notification letter was sent out, the NHA stated, One letter is sent out a year. When asked if the 4/23/26 notification letters provided were the most recent letters sent out, he stated, Yes and no additional letters have been sent out in 2026. When asked who helped residents to spend down, he stated, Me, and I'll have people help me. When asked who was monitoring and tracking to ensure follow through that the spend down happened, he stated, [the external consultant's company name] and me. When asked where the notification letters were stored, he stated, We have a file. It's stored on my computer. There are no other letters for 2026. The surveyor shared the concern that the facility did not provide evidence that notification letters had been provided to the RPs for 8 of the 10 residents. Additionally, the surveyor shared the concern that Residents #50 and #61 continued to have account balances at or above the notification threshold in July 2026, and the facility provided no additional documentation demonstrating compliance with the notification requirements after April 2026. The NHA acknowledged understanding of the concerns and offered no additional comments at that time. At this time the surveyor provided an additional opportunity for any and all further documentation to be provided by the facility for surveyor review. The NHA stated, I'm trying to work with IT (Information Technology) because it reached the period where the emails got deleted. The time period when emails get deleted is 3 months. On 7/31/26 at 12:46 PM in an interview with the NHA he stated there were no additional notifications outside of the 4/23/26 ones provided to the survey team for residents or RPs being notified when the resident's account reached $200 below the SSI resource limit or residents reaching the limit and being at risk of losing Medicaid or SSI benefits.

Based on observation, record review, and staff interview, it was determined that the facility failed to obtain a physician's order prior to the installation and use of bed rails. This was evident for 1 (Resident #91) of 2 residents reviewed for bed rail use.The findings include:On 07/27/2026 at 11:30 AM, observation of Resident #91 revealed bilateral bed rails in the raised position while the resident was in the bed.On 07/28/2026 at 2:25 PM, review of the electronic medical record revealed there was no physician's order authorizing the use of bed rails for Resident #91.On 07/29/2026 at 10:31 AM, review of the facility's bed rail policy revealed that the use of bed rails required a physician's order.On 07/30/2026 at 10:49 AM, during an interview, the Director of Nursing stated that the facility's process for bed rail use included an assessment, therapy evaluation, informed consent, installation by the maintenance department, and a physician's order. The surveyor shared the concern with the Director of Nursing that Resident #91 did not have a physician's order for the bed rails.The Director of Nursing confirmed that no physician's order was present in the medical record at 2:00 PM.

Based on record review and staff interview, it was determined that the facility failed to ensure a resident who received a psychotropic medication had an appropriate indication for use and appropriate care planning and monitoring. This was evident for 1 (Resident #11) of 1 resident reviewed for unnecessary medications.The findings include:On 07/30/2026 at 9:34 AM, record review of the electronic medical record (emar) for Resident #11 revealed an active physician's order for trazodone 100 mg, to give one tablet by mouth at bedtime for depression.At 9:53 AM, further record review of the electronic medical record revealed there was no documented diagnosis of depression in the medical record. Review of the resident's care plan also revealed there was no care plan addressing depression and no interventions or monitoring related to the resident's psychotropic medication.At 10:55 AM, the Director of Nursing (DON) was informed of the concerns that Resident #11 was receiving trazodone for depression without a documented diagnosis of depression, without a care plan addressing depression, and without documented monitoring for the psychotropic medication.On 07/31/2026 at 11:13 AM, review of the emar for Resident #11 revealed a new order for trazodone 100mg give 1 tablet by mouth at bedtime for insomnia dated 07/30/2026.

Based on record review and staff interview, it was determined that the facility failed to ensure required Medicare beneficiary notices were issued. This was found to be evident for 1 (Resident #129) of 3 residents reviewed for beneficiary notices during the recertification survey.The findings include:In a Skilled Nursing Facility (SNF), a NOMNC (Notice of Medicare Non-Coverage) and a SNF ABN (Advance Beneficiary Notice) are two distinct forms that notify a patient when Medicare coverage is ending. The NOMNC is an appeal notice issued at least two days before all Medicare-covered skilled care completely stops, providing the necessary contact information to file an immediate, fast appeal if the resident believes they still require medical therapy. In contrast, the SNF ABN is a financial liability waiver used when a patient chooses to remain in the facility or continue receiving services after Medicare stops paying, officially transferring the responsibility for the upcoming out-of-pocket bills directly to the resident.On 7/29/2026 at 9:23 AM, Resident #129's medical record was reviewed. Resident #129 was admitted to the facility on [DATE]. Census records reviewed showed the facility discontinued the resident's Medicare Part A skilled services on 3/27/2026, transitioning them to Medicaid Pending status, where they stayed in the building until a hospital transfer on 5/25/2026.A review of the resident's electronic medical record on 7/29/2026 at 10:43 AM revealed there was no evidence that a NOMNC and a SNF ABN was ever issued. On 7/29/2026 at 10:43 AM, the Nursing Home Administrator (NHA) provided the SNF Beneficiary Protection Notification Review form that was requested to be filled out. The form showed the facility initiated the discharge from Medicare Part A Services when benefit days were not exhausted and No was selected for both Was a SNF ABN provided and Was a NOMNC provided questions.During a subsequent follow-up interview and joint record review on 7/29/2026 at 11:00 AM, the NHA reviewed the beneficiary notice form with the surveyor and confirmed that Resident #129's Medicare Part A services were stopped by the facility with skilled days remaining and the resident remained in the facility, but the resident and/or Responsible Party never received a NOMNC and a SNF ABN required per federal regulation.

Based on interviews and record review it was determined that the facility failed to follow the grievance process for a resident. This was evident for 1 (Resident #11) of 1 resident investigated for personal property during the recertification survey.The findings include: On 07/28/26 at 8:47 AM during interview with Resident #11, it was revealed that s/he put money into the second floor's vending machine on Saturday 07/25/26 and the product s/he selected was not dispensed. Resident #11 stated that s/he was told by staff to complain to the front desk staff on Monday 07/27/26. Resident #11 stated that s/he complained to the receptionist, Staff #16, on 07/27/26. During an interview on 07/28/26 11 AM with Staff #16 , it was confirmed that s/he did receive a complaint from Resident #11 on 07/27/26 about the vending machine on the 2nd floor not dispensing Resident #11's item(s). Staff # 16, confirmed that s/he had not documented nor told anyone about Resident #11's concern, but would have told the vending machine contractor about it the next time they came to the facility. On 07/28/26 at 1 PM an interview with the Nursing Home Administrator (NHA) revealed that he was not aware of Resident #11's concern. However, the expectation was that the resident's concern was to be documented and made known to him by facility staff for appropriate follow up. 07/29/26 at 10:30 AM the NHA submitted documents to the surveyor, titled: Grievance/Complaint Report and a copy of the Vending Machine Maintenance Log regarding Resident #11's concern from 07/25/26. Review of the documents showed the Resident #11's concern was addressed and resolved with the resident on 07/28/26.

Based on interview, review of resident medical records, and interview with facility staff, it was determined that the facility failed to ensure that residents were provided with summaries of their baseline care plans. This was evident for 1 (Resident #42) of 3 residents reviewed for care planning during the recertification survey. The findings include: On 07/27/26 at 09:42 AM an interview with Resident #42 and her representative revealed that facility staff did not review or give them a baseline care plan since the resident's admission to the facility. On 07/29/26 at 10:20 AM a review of the resident's medical records revealed a baseline care plan evaluation that was only signed by the Social Services Director (Staff #6) on 07/16/26. There was no documentation to show the resident and their representative understood, acknowledged and received the baseline care plan noted on the evaluation. An interview with the Staff #6 was held on 07/29/2026 at 10:30 AM. Staff #6 confirmed s/he does not give the baseline care plan to residents or their representative.

Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to hold care plan meetings at least quarterly. This was evident for 1 (Resident #4) of 3 residents reviewed for care planning during the recertification/complaint survey.The findings include:Care plans are developed for residents to guide the care that residents receive in the facility. They are required to be developed within 7 days of completion of a resident's admission comprehensive Minimum Data Set (MDS) assessment and revised at least every quarter (or more often as needed). The facility is required to have care plans developed and revised by an interdisciplinary team including: the attending physician, a registered nurse, a nursing aide, a representative from dietary services, the resident, and the resident's representative (as practicable).On 7/27/26 at 10:23 AM in an interview with Resident #4, when asked if they attended care plan meetings, he/she stated, I have not been to any since I've been here. On 7/27/26 at 10:32 AM review of Resident #4's medical record revealed a document, Physician Certifications Related to Medical Condition, Substitute Decision Making and Treatment Limitations, which documented on 3/4/25 that in the section, Ability to Comprehend Information and Make Decisions each of the four statements were marked is able. Further review revealed a MOLST dated 10/24/25 that listed the patient, Resident #4, as who the physician certified that the orders listed were entered as a result of a discussion with and the informed consent of the patient. On 7/27/26 at 10:36 AM Licensed Practical Nurse (LPN #28) when asked if Resident #4 was his/her own Responsible Party (RP), she stated He/she's his/her own RP but has an emergency contact.On 7/27/26 at 10:37 AM in an interview with LPN #27 when asked if Resident #4 was his/her own RP, she stated yes.On 7/28/26 at 1:50 PM review of Resident #4's medical record revealed he/she was originally admitted to the facility on [DATE]. Further review revealed progress notes documenting care plan meetings held on 9/12/25, 4/17/26 and 7/14/26; however, failed to reveal documentation for a care plan meeting in June 2025, December 2025 or March 2026. On 7/28/26 at 2:10 PM in an interview with the Social Work Director, when asked about the facility's process for care plan meetings, she stated, We send a letter out to the families. The alert residents get a notice to their rooms. On the day of the actual care plan meeting, if the families can't be there in person, we call them on the phone to see if they can participate via the phone. The residents who are able and want to participate, we bring them to the meeting. When asked if a resident declined to participate would it be documented, she stated, It should be in a IDT (Interdisciplinary Team) progress note or care plan progress note. During the interview, when asked how often care plan meetings were held, she stated, Every 90 days. When asked, if a resident was admitted in March when their first care plan meeting would be held, she stated, Within 7 days of admission and sometimes that's also determined by the length of their stay. Other than that, they would be every 90 days except for short term residents. And families can also request one sooner. The surveyor requested documentation that quarterly care plans were being held for Resident #4. On 7/28/26 at 2:31 PM review of Resident #4's medical record failed to reveal any documentation that the resident declined to participate in care plan meetings or that participation was not practicable. On 7/29/26 at 9:08 AM in an interview with the Social Work Director she stated, The issue is going back one year I don't see anything. I'll have to see if I can get it from medical records. I don't have June or December 2025 documentation of a care plan meeting. During the interview when asked when the next care plan meeting should have been held, she stated, It should have been March 2026. When asked why consistent care plan meetings were not being held, she stated, I started April 2025, previous to that, I'm not sure, I'd have to follow up. On 7/29/26 at 10:34 AM the surveyor made a second request for June and December 2025 care plan documentation for Resident #4.On 7/29/26 at 10:55 AM in an interview with the Social Work Director she stated, I do not see and medical records did not see documentation of a June or December 2025 care plan meeting. The surveyor shared this was a concern as the Social Work Director acknowledged understanding of the concern and offered no further comments at that time.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that nebulizer equipment was stored in a clean, covered container when not in use. This was found to be evident in 1 (Resident #93) of 2 residents reviewed for respiratory care during the recertification survey.The findings include:During an observation on July 27, 2026, at 9:20 AM, Resident #93 was asleep in bed. A nebulizer, tubing, and a nebulizer mask were located at the bedside. The nebulizer mask was dry and resting directly on the resident's bedside table without a plastic bag cover or a paper towel underneath.During a subsequent observation on July 27, 2026, at 11:38 AM, Resident #93 was out of the room. The nebulizer mask remained uncovered on the bedside table and was not observed inside a plastic storage bag.During an interview on July 27, 2026, at 11:40 AM, Agency Licensed Practical Nurse (LPN) #3 toured the room with the surveyor. LPN #3 observed the uncovered nebulizer mask at the bedside. LPN #3 stated that the facility's expectation is for the nebulizer mask to be stored in a clean plastic bag when staff are not using the equipment.During a record review on July 28, 2026, at 10:19 AM, the surveyor reviewed the facility's Nebulizer Therapy policy. The policy was implemented on January 27, 2023, and reviewed by the facility on October 27, 2025. Under the Care of the Resident section, guideline number seven specified: Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag.During an interview on July 28, 2026, at 10:43 AM, the Director of Nursing (DON) confirmed that facility policy requires staff to appropriately clean the nebulizer mask and store it in a clean plastic bag when it is not in use.

Based on review of medical records and interview with facility staff, it was determined that the facility failed to ensure that the attending physician documented in the medical record that a medication irregularity was reviewed and pharmacist-identified irregularities were acted upon. This was evident for 1 (Resident #3) out of 5 residents reviewed for unnecessary medications during the facility's recertification survey.The findings include:The Medication Regimen Review (MRR) is a thorough review of the medication regimen (plan) of each resident with the goal of promoting positive outcomes and minimizing adverse (negative) consequences and potential risks associated with medications. The MRR must be completed at least once a month by a licensed pharmacist and includes a review of the residents' medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. Irregularity refers to use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or interferes with achieving the intended outcomes of pharmaceutical services. An irregularity also includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy.On 7/29/26 9:57 AM review of Resident #3's medical record revealed Pharmacy Consultant notes documenting see report on 10/2/25, 12/19/25 and 2/15/26. Copies of the referenced reports were not available in the resident's medical record during the initial review and were provided by the DON only after surveyor request.On 7/29/26 at 10:01 AM in an interview with the Director of Nursing (DON) when asked about the facility's MRR process, she stated the pharmacy consultant sends us a monthly review and we read it to see if there were any recommendations. If there were no recommendations, we'd document it and if there were recommendations, we'd let the physician know and they'd decide if they wanted to move forward or keep things the same. During the interview she said that after the pharmacist reviewed the residents' medications, if something were urgent, she'd call or send an email. When asked how the report was sent, she stated it was emailed to the management team, who she clarified as the DON, Assistant Director of Nursing (ADON), and the nurse managers/supervisors. When asked if those were the only facility staff to receive the report, she stated, yes. When asked if the Nursing Home Administrator (NHA), the medical director, or physicians received it, she stated, The NHA gets a separate email. The medical director, we discuss it with him, and we discuss it with the providers as well. When asked how the providers reviewed the MRRs, she stated, We can hand it to them if they're in the facility and if they're not in the facility we call them and get a verbal order. When asked if the recommendations had the three boxes (Agree, Disagree, Other) in the Physician/Provider Response section at the bottom of the individual recommendations she stated yes. When asked if it was the expectation that the Physician/Provider reviewed the recommendation, checked one of the three boxes and signed/dated the form, she stated, If they're in the facility. If they're not, the nurse can review, sign it and put in a telephone order. When asked if it was the expectation that if the Physician/Provider disagreed that they would write a rationale as to why and she stated, Yes, the provider should write a rationale if they disagree with the recommendation. When asked who was responsible for putting in new orders and/or discontinuing previous orders, she stated, Any nurse can do that. When asked how facility staff would know who was responsible for doing so after any given MRR, she stated, The nurse management team looks at the recommendations, many times we'll put in the orders, but it can be delegated to another nurse to do. When asked who was responsible for following through to ensure that this entire process had been completed, she stated, Myself and the ADON. When asked where the recommendations were stored, she stated, We keep a copy in the ADON's office. When asked if that was part of the medical record, she stated, And it's uploaded in PCC (Point Click Care). The surveyor requested the individual recommendations from 10/2/25, 12/19/25 and 2/15/26's recommendations for Resident #3. On 7/29/26 at 11:30 AM the DON provided copies of the referenced recommendations. Continued review revealed that the 2/15/26 recommendation documented: Resident has an order in PCC for amlodipine 10 mg (milligram) tablet to give 0.5 tablet by mouth one time a day for HTN (hypertension). Amlodipine is commercially available as 5 mg whole tablets. Please review. Resident has an order in PCC for losartan 100 mg tablet to give 0.5 tablet by mouth one time a day for HTN (hypertension). Losartan is commercially available as 50 mg whole tablets. Please review. In the Physician/Provider Response section at the bottom of the individual recommendation, the Agree Please update medication orders/changes in EHR (electronic health record) box was checked. Subsequent interview confirmed the signatures were not those of the attending physician, and review of the medical record failed to demonstrate documentation by the attending physician that the pharmacist-identified irregularities had been reviewed. On 7/29/26 at 12:13 PM review of Resident #3's medical record failed to reveal a current, active order or discontinued order for Amlodipine 5mg or Losartan 50 mg. The review failed to reveal documentation by the attending physician that the pharmacist-identified irregularities dated 2/15/26 had been reviewed or what action, if any, had been taken to address the recommendations.On 7/29/26 at 1:33 PM in an interview with the DON, she stated that the signature for the 12/19/25 and 2/15/26 recommendations was the ADONs. The surveyor requested a copy of the 5 mg Amlodipine and 50 mg Losartan orders for Resident #3. On 7/29/26 at 2:43 PM in an interview with the DON, when asked if she had a copy of the 5 mg Amlodipine and 50 mg Losartan orders for Resident #3, she stated, No, for the for both of these, it was a failure to transcribe. This confirmed that the recommendation had been agreed to, as reflected by the documented telephone order, but the revised medication orders were not ordered due to a failure to transcribe them. During the interview, a dual observation of the 10/2/25 recommendation was conducted and when asked who had signed it, she stated, Let me look and see I think it's one of my supervisors. What's the issue with this one? Oh, a doctor didn't sign it. Let me see if it's the Attending Physician's NP (Nurse Practitioner). The surveyor shared the concern that for the 12/19/25 recommendation a nurse had signed it and there was no evidence in the medical record the attending physician had reviewed it. The DON acknowledged and confirmed understanding of the concern and offered no further comment at that time. On 7/29/26 at 3:01 PM in an interview with the DON she stated that the 10/2/25 signature was [first and last name of nursing supervisor]. The surveyor again shared the concern that for the 10/2/25 and 12/19/25 MRR a nurse had signed the recommendation and there was no evidence in the medical record the attending physician had reviewed the recommendations. When asked if she could confirm by looking at the medical record that the provider had reviewed the 10/2/25 or 12/19/25 recommendation from the pharmacist she stated, no.

Based on observation, interview, and record review, it was determined that the facility failed to have a medication error rate of less than 5% during the medication observation facility task. This was evident for 2 of 26 medications administered during the observation.The findings include:On 07/29/2026 at 8:34 AM, Staff #25 was observed administering medications to Resident #9. During the medication pass, Staff #25 administered 10 medications that were due to be given at 9:00 AM, but did not administer two ordered medications, metoprolol and Jardiance, that were also due at 9:00 AM. Staff #25 stated that the medications were not in the medication cart and stated, I will give those medications by 9:45 AM. The surveyor continued observations.At 9:54 AM, the surveyor asked Staff #25 whether the 2 remaining medications had been administered to Resident #9. Staff #25 stated that the metoprolol for Resident #9 was in Staff #9's possession, but that he/she still needed to obtain the Jardiance. Continued observation through 10:08 AM showed that Resident #9 had still not received either of the two ordered medications.At 10:17 AM, the surveyor reviewed the electronic medical record for Resident #9 and confirmed the ordered times for the metoprolol and Jardiance to be 9:00 AM. On 07/30/2026 at 10:54 AM, the Director of Nursing (DON) was informed that the medication observation identified a medication error rate of 7.69%. The observation findings were shared with the DON regarding the 2 late medications.

Based on observation, interview, and record review, it was determined that the facility failed to ensure medications were stored in accordance with professional standards and manufacturer guidelines. This was evident for 1 of 2 medication rooms and 1 of 4 medication carts reviewed, and for Resident #93 during an observation of the resident's room during the recertification survey.The findings include: 1) On [DATE] at 11:41 AM, observation of the 2 East medication room revealed an opened vial of Tuberculin Purified Protein Derivative, Diluted Aplisol 1 mL that had no date indicating when it was opened. This vial was intended for multiple uses and was kept in a medication refrigerator among other medications. The directions on the medication label stated that the vial was to be discarded 30 days after opening and no date was found on the vial indicating when it had been opened. Further observation also revealed two bottles of liquid famotidine labeled for Resident #1 that remained in active medication storage. One bottle had expired on [DATE], and the second bottle had expired on [DATE]. At 11:47 AM, the Unit Manager (Staff #4) accompanied the surveyor to the medication room, observed the undated Aplisol vial and the two expired bottles of liquid famotidine, and was made aware of the findings. At 2:00 PM, the Director of Nursing was notified of the medication storage findings. 2) During an observation on [DATE], at 9:20 AM, Resident #93 was asleep in bed. A box of Duo-Neb medication (Ipratropium Bromide and Albuterol) was located unsecured on the resident's bedside table. The medication was observed inside the box. Record review of Resident #93's Minimum Data Set (MDS) assessment located in the Internet Quality Improvement and Evaluation System (iQIES) demonstrated that the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. At 9:23 AM, Licensed Practical Nurse (LPN) #3 observed entering the room to perform a medication pass. During a subsequent observation on [DATE], at 11:38 AM, Resident #93 was out of the room. The Duo-Neb medication box remained unsecured on the bedside table. During an interview on [DATE], at 11:40 AM, LPN #3 toured the room with the surveyor. LPN #3 observed the Duo-Neb medication box at the bedside. LPN #3 stated that the facility's expectation is that medication is not kept in a resident's room. During a record review on [DATE], at 10:09 AM, the surveyor reviewed the facility's Medication Storage Policy. The policy was implemented on [DATE], and reviewed by the facility on [DATE]. Under section 1) Policy Explanation and Compliance Guidelines A) General Guidelines, item a specified: All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. During an interview on [DATE], at 10:43 AM, the Director of Nursing (DON) stated that they investigated and interviewed the resident, who indicated it was an old medication given to him/her before admission to the facility, and that the resident pulled it out of her bag when cleaning. The DON noted that the medication was from a different pharmacy than the one the facility uses, and stated that a progress note had been placed in PointClickCare (PCC) regarding the incident. Surveyor addressed concern that medication was not removed prior to surveyor intervention.

Based on interviews and observation, it was determined that the facility failed to serve meals that were the appropriate temperature and in a timely manner. This was evident during a tray line observation.Findings include:During an observation of the tray line on 7/28/2026 at 11:45 AM, it was observed that the food for the 1st floor residents was placed on a non-insulated storage rack instead of an insulated food cart. The District Dietary Manager was asked why the food trays were not in an insulated food cart and told that the facility did not have enough to serve the building.The tray line ran out of food before all residents could be served. The Kitchen Manager prepared more food that included substitutions for the missing food. It was 1:45 PM before the trays left the kitchen and 2:30PM before the last tray (the survey test tray) was delivered. The District Dietary Manager was asked why the kitchen ran out of food and he said he didn't know. At the time the test tray was delivered the entree, a turkey burger temperature was 134 degrees (hot food is expected to be from 145-165 degrees) and the green pea salad was 49 degrees (cold food should be less than 41 degrees). The temperatures were taken by the Kitchen Manager using their thermometer

Based on interviews, observation, and review of the facility's documentation, it was determined that the facility failed to provide a meals based on residents' preference. This was evident of 1 of 6 residents (Resident #14) reviewed for accuracy of meals during an annual survey. The findings include: During initial screening on 07/27/2026 at 11:34 AM, Resident # 14 stated, I don't eat the food here. I had the spaghetti and meatballs and had diarrhea for 5 days after. My [spouse] brings me food every day because I would rather go hungry than eat the food. There is no variety. Breakfast is scrambled eggs and toast- no meat. And that's almost every day. After reviewing the menu provided by the facility, the lack of variety and breakfast meat was verified. The menu had the residents being served some sort of eggs 5 days a week with French toast or pancakes on the other 2 days. Breakfast meat is served 3 days a week. Resident #14 stated that they requested breakfast meat every day but seldom got it.On 7/28/2026 at 10:30 AM, the facility dietician was interviewed and the residents concern about the lack of variety and breakfast meat was brought to her attention. She stated that the the company contracted by the facility to provide dietary services made the menu and provided the food. In a follow-up interview with the District Dietary Manager for the contracted company he said that the facility was given a variety of menus to choose from and that the facility had chosen the one that was currently being served.

Based on interview, observations and record review, it was determined the facility failed to ensure the most recent survey results were posted and readily accessible. This was evident during the facility's recertification survey. The findings include: On 07/28/2026 at 1:25 PM the surveyor inspected the reception area for a posted notice or signage to locate the survey results and none was found. An interview with the receptionist, during the inspection, revealed the survey results (in a binder) was kept within his/her reach behind the desk. On 07/28/26 at 1:27 PM the surveyor toured the reception area of the facility with the Nursing Home Administrator (NHA) who confirmed the survey results were kept behind the receptionist's desk. The surveyor shared concerns with the NHA that a posted notice or signage was absent, which would direct residents or visitors of the survey results location. On 07/28/26 at 1:33 PM surveyor review of the survey results binder revealed that the most recent survey results and plan of corrections were not available in the binder. The most recent survey result and plan of correction available in the binder was from a survey dated 11/16/23. The facility had a recertification survey during 2025. On 07/28/26 at 1:48 PM an interview was held with the NHA who confirmed that the most recent survey results and their respective plan of corrections were not available in the survey binder.

Based on observation rounds and interviews, the facility failed to maintain an infection prevention and control program that properly identified the isolation necessary for residents, maintain infection prevention standards during resident care, and properly store and process linens to prevent the spread of infection to residents following accepted national standards. This was evident for 5 (#15, #110, #66, #45, and #89) of 55 residents and 1 of 2 of the laundry rooms observed during survey. The findings include: Enhance Barrier Precautions (EBP): Enhanced Barrier Precautions are used as an infection control intervention that uses targeted gown and glove use during high-contact resident care activities in nursing homes to reduce the transmission of multidrug-resistant organisms (MDROs). 1. During initial observation rounds and medical record review on 06/11/25 at 07:45 AM for Resident #15 surveyor observed an Enhanced Barrier Precaution (EBP) sign present on the resident room door, however no Infection Control supplies observed near or within room for staff to use to maintain infection prevention standards for this room. Per medical record review for Resident #15, it revealed a medical order Enhanced Barrier Precautions to be maintained at all times; VRE, every shift, dated 1/19/2025. 2. During initial observation rounds and medical record review on 06/11/25 at 07:52 AM for Resident #110 surveyor observed EBP signage on the resident door of a double-occupancy room, however the surveyor was unable to determine which resident required precautions. Per medical record review for Resident #110, it revealed a medical order Enhanced Barrier Precautions to be maintained at all times, every shift for ESBL Escherichia coli in the Urine, dated 4/9/2025. 3. During initial observation rounds and medical record review on 06/11/25 at 07:55 AM for Resident #66 surveyor observed EBP signage on the resident door of a double-occupancy room, however the surveyor was unable to determine which resident required precautions. Per medical record review for Resident #66, resident was not on EBP and no medical orders revealed EBP needs. 4. During initial screening rounds on 06/11/25 at 08:02 AM for Resident #45 surveyor observed signage indicating gown and glove donning and doffing with no other infection control type signage on the resident door of a double-occupancy room, and surveyor was unable to determine which resident was to be maintained on precautions. Per medical record review for Resident #45, resident was not on EBP and no medical orders revealed for EBP needs. 5. During initial observation rounds and medical record review on 06/11/25 at 07:52 AM for Resident #89 surveyor observed signage indicating gown and glove donning and doffing with no other infection control type signage on the resident door of a double-occupancy room, and the surveyor was unable to determine which resident was to be maintained on precautions. Per medical record review for Resident #89, it revealed a medical order Enhanced Barrier Precautions to be maintained at all times, every shift dated 8/7/2024. During interview on 06/11/25 at 07:50 AM with Geriatric Nursing Assistant #25 surveyor asked how do they know which resident the EBP signage applies to in a double-occupancy room. Staff #25 stated they did not know how residents were identified. During interview on 06/11/25 at 08:22 AM with Infection Prevention Nurse #23 surveyor discussed infection prevention supplies for staff, EBP signage and determining which resident it applies to in a double-occupancy room. Staff #23 stated that a resident is identify by a green dot placed next to the resident name on the room door tag that requires EBP. Staff #23 was notified of various rooms with inconsistencies of green dot placement. 6. During observations on 06/17/25 at 01:37 PM in the laundry room of the facility where the clean laundry is processed, there were two cement walls with brown stains and peeling damp to touch paint noted over approximately 50% of ceiling and the cement walls, as well as a large hole in the ceiling with debris protruding from the hole. The clean laundry was noted to be folded and stacked against the effected cement walls of concern and directly below the hole within the ceiling in this room. During interview on 06/17/25 at 02:00 PM with Nursing Home Administrator #1 the surveyor discussed and made aware of laundry room conditions.

Based on interviews with residents and facility staff and record reviews, it was determined the facility failed to ensure that residents choices for discharge were properly facilitated by the facility staff. This was found to be evident for 2 (Resident #17 and #91) out of 4 residents reviewed for Choices during the facility's survey. Findings include: 1. An interview was conducted with Resident #17 on 6/11/25 at 1:20 PM and the resident was asked the question, if s/he can make choices about their daily life. The resident stated that s/he would like to have a private place to live. The resident went on to say that s/he would like to have family and friends visit where there is privacy, no restrictions and can go outside and get fresh air whenever s/he desires. Resident # 17 stated that s/he would like to be in a place where there are healthy and highly functioning people like him/her, and not in a place surrounded by people who are much older. The resident went on to say that the discharge process was started three times previously and not completed due to staff leaving, and that s/he and other residents are waiting for assistance with discharge. An interview was conducted with the Director of Social Worker (DOSW) (#8) on 6/11/25 at 2:00 PM and she was asked about Resident #17's discharge plans and if she was aware of the resident desire to be in a setting that allowed the resident to have his/her own privacy. The DOSW stated that she has only been in her position for thirty (30) days. She stated that she will follow up with the resident. 2. An interview was conducted with Resident #91 on 6/13/25 at approximately 11:00AM and S/he said to the surveyor that s/he would like to leave the facility but has not been able to get assistance with this process. The resident further stated that s/he is highly functioning and would like a place of their own. The resident stated that no one has followed up for months. An interview was conducted with the Nursing Home Administrator on 6/13/25 at 9:25 AM he confirmed that the current DOSW (#8) has been working at the facility for approximately 30 days. He confirmed that the previous Social Worker (SW) last day of work was on 1/17/25. The Administrator told the survey team that a consultant was providing services to the facility once a month. During another interview with DOSW #8 on 6/13/25 at 2:00 PM she stated to the survey team that she was currently working with both residents and that both Residents #17 and #91 were highly functioning and in stable health. She provided documentation of a previous social work note for Resident #17 dated October 2024 and a previous social work note dated 11/26/24 for Resident #91. She told the survey team that she was unable to provide follow-up social work documentation for Resident #17 and #91 during the absence of the previous social worker who left in January 2025. All concerns were discussed at the exit conference on 6/18/25 at approximately 2:00 PM.

Based on record reviews and staff interviews, it was determined that the facility failed to provide Medicare beneficiaries with 1) Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage and 2) Notice of Medicare Non-Coverage. This was evident for 2 (Residents #50 and #72) out of 3 residents selected during the Beneficiary Protection Reviews. The findings include: The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form (CMS-10055) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The Notice of Medicare Non-coverage form (CMS-10123) informs the beneficiary of his/her right to file an appeal of the decision and the right to an expedited review of Medicare non-coverage of services. 1) On 06/17/25 at 11:58 AM, a review of the SNF Beneficiary Protection Notification Review form (CMS-20052, completed by the facility, indicated that Residents #50 and #72 were not provided with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form (CMS-10055). The facility checked the box for the option that stated *If NOT issued and should have been: F582. On 06/17/25 at 12:10 PM, the Nursing Home Administrator #1 was interviewed. During the interview, the surveyor informed Administrator #1 that the SNF Beneficiary Protection Notification Review form (CMS-20052), for Residents #50 and #72, indicated that Residents #50 and #72 were not provided with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form (CMS-10055), and that the option, which stated *If NOT issued and should have been: F582, was selected. In response, Administrator #1 indicated that Residents #50 and #72 were not provided with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage form (CMS-10055). 2) On 06/17/25 at 11:58 AM, a review of the SNF Beneficiary Protection Notification Review form (CMS-20052), completed by the facility, indicated that Resident #72 was not provided with the Notice of Medicare Non-coverage form (CMS 10123). The facility checked the box for the option that stated *If NOT issued and should have been: F582. On 06/17/25 at 12:10 PM, Administrator #1 was interviewed. During the interview, the surveyor informed Administrator #1 that the SNF Beneficiary Protection Notification Review form (CMS-20052), for Resident #72, indicated that Resident #72 was not provided with the Notice of Medicare Non-coverage form (CMS-10123), and that the option, which stated *If NOT issued and should have been: F582, was selected. In response, Administator #1 indicated that Resident #72 was not provided with the Notice of Medicare Non-coverage form (CMS-10123).

Based on review of medical records and facility investigation documentation, interviews and observations it was determined the facility failed to have an effective system in place to prevent residents with cognitive impairment from leaving the facility without appropriate supervision. More specifically, the facility failed to: 1.) Provide adequate supervision to prevent a resident with known wandering and exit seeking behaviors from exiting the facility unsupervised on 5/10/21, 2.) Ensure all staff check the functionality of the wander guard bracelets for residents currently in the facility with a bracelet in place that have exit seeking behavior; 3.) have an elopement risk binder on all nursing units and educate all staff on the location and purpose of the elopement risk binder and 4.) educate all staff, including agency staff to monitor their surroundings when entering and exiting the facility. These actions resulted in the finding of an Immediate Jeopardy which was identified on 8/2/22 at 9:40 AM. This deficient practice was evident for 2 of 2 residents (Resident #208, #84) reviewed for elopement/wandering during the annual survey. Additionally, the facility staff failed to ensure residents received protective devices that were intended to protect the resident from injury due to a fall. This was evident for 1 of 6 residents (Resident #17) reviewed for accidents during the annual survey. The findings include: According to the Centers for Medicare and Medicaid Services (CMS), an Elopement occurs when a resident leaves the premises or a safe area without authorization. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complications, drowning, or being struck by a motor vehicle. The resident at risk should have interventions in their comprehensive plan of care to address the potential for elopement. BIMS stands for Brief Interview for Mental Status. It is a screening tool used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. There is a series of questions that are asked to the resident. These questions have a score value attached to them. The total score of all the questions ranges from 0-15. The numeric value falls into one of three cognitive categories: Intact which is 13 to 15 points, Moderate which is 8 to 12 points or Severe cognitive impairment which is 0 to 7 points. 1) A review of Resident #208's medical record on 8/1/22 at 9:00 AM revealed the resident was first admitted to the facility in February 2021 from an acute care facility with the primary diagnosis as stroke. An elopement evaluation dated 2/26/21 documented Resident #208 was a high risk for elopement as the resident was ambulatory, could communicate, had a history of wandering, and had wandered aimlessly within the building. A 2/26/21 admission note documented Resident #208 was alert to self and required reorientation frequently. Resident #208 was deemed a high fall risk due to the ability to get out of bed and wander. A 2/28/21 at 23:42 (11:42 PM) nurse's note documented Resident #208 was alert and confused and continued to wander around the unit looking for his/her sister. A nursing note on 3/1/21 at 6:14 AM documented Resident #208 wandered all night and continued to need redirection and orientation. Resident #208 was discharged home with his/her spouse in the end of March 2021. On 8/1/22 continued review of Resident #208's medical record revealed Resident #208 was readmitted to the facility towards the end of April 2021. The hospital discharge summary documented that the resident was brought by ambulance to the emergency room after being found wandering outside with no shoes. The documentation noted the resident was confused and attempted to wander around the emergency room . The facility Elopement Risk Evaluation dated 4/20/21 identified Resident #208 as high risk for elopement as the resident was ambulatory, had a history of wandering, medical diagnosis of dementia/cognitive impairment, and has wandered aimlessly within the house and off the grounds. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. On 8/1/22 a review of Resident #208's admission Minimum Data Set (MDS) assessment, with an assessment reference date of 4/21/21, coded that Resident #208 had a BIMS score of 1 under Section C, cognition. Section E, wandering, coded wandering has not occurred and answered no to intrude on privacy of others. This was inaccurate according to a nursing progress note dated 4/21/21 at 6:45 AM which documented Resident #208 wandered during the night from room to room and had to be redirected several times. On 8/1/22 a review of Resident #208's care plan, elopement risk/wandered AEB (as evidenced by) disoriented to place. Resident wanders aimlessly, dementia, that was initiated on 5/1/21, had 2 interventions, distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book and wander alert: left ankle. On 8/1/22 a review of facility-reported incident MD 212 revealed that on 5/10/21 at 6:58 AM, Resident #208 was last seen while the nurse was administering medications. Police brought Resident #208 back to the facility at about 8:30 AM on 5/10/21. Resident #208 was found two doors down from the facility by the police officer. The facility's investigation determined the wander guard system was working. Review of a written statement from the RN night shift supervisor #24, documented that around 6:50 AM Resident #208 was sitting in the lobby and attempting to push the front door but was redirected, was receptive and went back upstairs to the unit. Resident #208 was again observed to be in the lobby, but Staff #24 was checking incoming staff in and outgoing staff out and did not see when Resident #208 exited the front doors. A review of a 5/10/21 written statement from Geriatric Nursing Assistant (GNA) #27 documented that Resident #208 was up all-night walking all over the second floor. At 6:45 AM GNA #27 noticed the resident was not around, so she started asking if anyone had seen the resident. GNA #27 went downstairs and one of the GNA's saw the resident and told him/her to go back upstairs. GNA #27 documented that she said, why didn't someone bring him/her back upstairs. GNA #27 documented that she started to go outside, and the police showed up and asked if the resident lived at the facility. The police brought Resident #208 back in the building. A review of nursing notes dated 5/10/21 at 7:50 AM, Patient [Resident #208] alert and oriented x 1, awake during this shift, walking around the nursing station. Patient [Resident #208] received his/her medication at 6:58. The note continued, GNA notified me around 7:04 that she can't find [Resident #208] in his/her room or walking around the hallway on the second floor. Supervisor notified and Elopement code was called. Patient [Resident #208] was brought back safely by the police officer. On 8/1/22 at 8:46 AM an interview was conducted with the Nursing Home Administrator (NHA). The NHA stated Resident #208 was sitting at the front door and got in-between 2 people and got out, unfortunately. The door did not alarm. In the panel, the alarm volume setting was on low, and we immediately raised the volume to high and that was the problem. The NHA was asked why it was on the low setting and his response was he did not know. The NHA stated the wander guard bracelet was working. The NHA stated it was change of shift and that was part of the issue because it was louder in the lobby. The NHA was asked to provide the surveyors with a copy of the investigation along with any other documents to support the facility's actions. Review of the medical record on 8/1/22 at 9:00 AM revealed a 4/28/22 at 6:44 AM nurse's note which documented, resident did not sleep throughout the night, resident made several attempts to exit but redirected. The note stated, resident kept saying I want to go home to my mother. A 5/1/21 at 6:27 AM nurse's note documented that Resident #208 did not sleep all night, wandered around, and was redirected several times. A 5/1/21 at 7:58 AM note documented, persistent to leave facility this am. was stated by night staff resident has been awake all night, was given prn [MEDICATION(S)], no change. Resident stated my daddy is going to pick me up, I have to leave. CRNP updated, supervisor aware of resident's increased wandering. The resident is being closely monitored at this time. residents' wander guard is in place of the left ankle. A 5/4/21 at 6:02 AM note documented, Resident did not sleep through the night, wandering from unit to another, several attempts made to situate resident. Noncompliance. A 5/4/21 at 1:13 PM social services discharge planning note documented that nursing, rehab, activities, and social work discussed with the family via telephone Resident #208's advanced dementia, wandering risk and safe environment options. It was the recommendation of the team that the resident be in a long-term setting with a dementia unit, with one-to-one supervision. A 5/6/21 at 8:23 PM nurse's note stated, Resident wandering around in the Lobby area, attempting to open the doors. Staff continues to redirect and take back upstairs. Wander guard remains in place on [his/her] left ankle. A 5/7/21 at 7:19 AM nurse's note documented that the resident wandered all night, was redirected several times but kept wandering up and down the building and only slept for 2 hours. On 8/1/22 at 7:41 AM Police Officer #28 was interviewed and stated, the resident was walking down the street from the facility and fortunately I was sitting at the end of the street. [He/she] was not dressed appropriately to be walking down the street. [He/she] was wearing PJs, socks, and no shoes. Not appropriate for being outside. He stated, it took me a while to figure out who [he/she] was. [He/She] said [he/she] was going home to [spouse]. Police Officer #28 stated he looked through the resident's belongings, which was some type of satchel. He said he took the resident back to the facility. On 8/1/22 at 7:52 AM during an interview with the night shift supervisor, Staff #24, two resident pictures were observed on the bulletin board at the front desk. Staff #24 confirmed the pictures were of the two residents in the building that were currently elopement risks. Staff #24 was able to produce an elopement binder with the two resident's information. Staff #24 stated, there is always someone at the front desk until 8 PM. There is a camera at the front desk and at the 1 west nurse's station. The front door is alarmed and needs a code to get out for it to open. The wander guard will sound even if the door is open to let someone in. The Maintenance Director was interviewed on 8/1/22 at 9:09 AM. The Maintenance Director stated, all exit doors are checked every day, Monday through Friday. On 8/1/22 at 10:31 AM the NHA provided the surveyor with the education that followed the elopement. The employee signature sheet for Clinical Policy - Elopement described the elopement procedure. The policy documented the facility will assess residents for elopement risk by completing the Elopement Risk Assessment on admission, annually and with changes in condition that may interfere with resident's mental status. Residents identified as at risk, will have an updated care plan with appropriate interventions. The education failed to address shift change and the opportunity for residents to slip past staff. A review of the elopement policy that was given to the surveyor on 8/1/22 at 11:32 AM documented, alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. On 8/1/22 at 3:46 PM LPN #29 was asked if anyone on his unit (1 West) had a wander guard bracelet. LPN #29 stated, just about everyone wears a wander guard. RN #30 (agency nurse) was standing next to LPN #29 and stated, I know nothing. I would direct you to the unit manager or Director of Nursing. On 8/1/22 at 3:50 PM LPN #31 was asked if she knew who on her unit was an elopement risk. LPN #31 stated, this is my first day. LPN #31 was asked if she was oriented to the unit and she stated, it depends on if it is a [corporate name] facility. LPN #31 stated she was not oriented here, just told her schedule. LPN #31 was asked if there was an elopement binder on the unit and her reply was, I have not seen one. On 8/2/22 at 7:28 AM the surveyor asked LPN #26, who was on the second floor, 2 East unit, if there was an elopement binder for the unit. LPN #26 looked all through the nurse's station along with 2 other nurses and stated, we used to have one, but I can't find it. When asked if there was anyone on the unit that was an elopement risk she stated, I don't think so. On 8/2/22 at 7:31 AM GNA #32 (agency) was on the second-floor west wing unit and was asked if any of her residents were an elopement risk. GNA #32 stated, I don't think so. GNA #32 stated, if anyone wears a wander guard it will go off if they try to leave. GNA #32 was asked if she was educated prior to her shift about elopement and she stated, no. On 8/2/22 at 7:33 AM LPN #33 (night shift) was asked if he checked the wander guard for Resident #84. Resident #84 is 1 of 2 residents in the facility that was an elopement risk. LPN #33 stated, I occasionally check it. He/she has physical limitations. I don't need to check it because [his/her] room is right next to the nurse's station. On 8/2/22 at 7:36 AM Resident #84's medical record was reviewed and revealed a physician's order, use wander guard universal tester to check that wander guard bracelet is functioning. Replace bracelet if not working properly. Document replacement under progress note tab in [name of electronic medical record]. Every night shift for elopement precaution. Order date 5/4/22 at 1402. Review of Resident #84's Treatment Administration Record (TAR) for August 2022 revealed LPN #33's initials and checkmark that he checked the bracelet on night shift of 8/1/22. On 8/2/22 at 7:41 AM, with a second surveyor, another interview with LPN #33 was conducted. LPN #33 was asked if he checked Resident #84's wander guard bracelet for function and he said, no. The surveyor asked LPN #33 to open Resident #84's TAR and the surveyor pointed out that he signed off that the wander guard check was done. LPN #33 stated, there is the alarm over there by the door. The surveyor read the order to LPN #33 and pointed out that he signed off that he checked the resident's wander guard functionality. LPN #33 confirmed that he did not check the wander guard even though he signed off on the TAR that he did check it. At that time the surveyor asked LPN #33 to go into Resident #84's to confirm placement of the wander guard. Resident #84 was not wearing the wander guard. It was placed on the wheelchair due to the resident's refusal to wear it. On 8/2/22 at 7:43 AM it was also confirmed by LPN #10 that there was no elopement binder on the 2 West nursing unit. On 8/2/22 at 7:54 AM the Director of Nursing (DON) was informed of the conversation with LPN #33. The DON was also asked about elopement binders on the units, and she stated there was an elopement binder at the front desk and in the conference room where the supervisors were located. The DON also stated that information should be exchanged in report between shifts. From 7/22/22 until 8/2/22, the surveyors would arrive at the facility at approximately 7:00 AM and observe shift change from night to days. There were always several staff standing in the lobby in front of the check-in window, either getting their temperature checked and screened for COVID-19 symptoms or agency staff checking in or out with the night shift supervisor. It was observed that when there were staff standing in front of the screening window and the night shift supervisor was looking down at paperwork or a phone, the night shift supervisor could not see who or what was going on at the front door. Staff would hold the door open for the next person to walk in or out. Because of these findings, an Immediate Jeopardy was identified on 8/2/22 at 9:40 AM. A final plan to remove the Immediate Jeopardy was submitted to the surveyors on 8/2/22 at 4:30 PM. On 8/3/22 at 3:40 PM the NHA came to the surveyors and stated, I did some digging and found more education and information from the elopement in 2021. The NHA presented a binder of all education and everything the facility had put into place. This binder was not provided to the surveyors on 8/2/22 and was not an option to review before the Immediate Jeopardy was identified. Education sign-in sheets that were provided to surveyors on 8/3/22 at 3:40 PM for the elopement on 5/10/21 were compared to the current staffing roster that was provided to surveyors on entrance to the facility on [DATE]. It was noted that (2) requests had been made for a complete staffing list for May 2021 on 8/4/22 and 8/5/22 at 9:30 AM and as of 3:30 PM on 8/5/22 the list was not provided. There were 31 staff names with a date of hire prior to 5/10/21 that were not educated that were on the current staffing roster. Additionally, the Wandering and Elopements Policy that was given to the surveyors from the time of the initial elopement did not match the policy that the staff were educated on 5/10/21. The policy that staff were educated on 5/10/21, had a date issued 11/15 on the lower left-hand corner of the page. The policy described the elopement procedure. The policy the facility provided to the surveyors in the binder on 8/3/22 had an April 2019 date in the lower left-hand corner of the page. On 8/11/22 at 11:14 AM the nursing staffing scheduler was interviewed and stated, the staff on most days and shifts are agency. She stated, on weekends the numbers can go up to 75% agency. On a given day more than half of our staff is agency. She stated, we have a book on the unit for agency staff that has information on how to handle situations, policies, and procedures. On the weekends it is a lot of agency staff, but we make sure there is a supervisor for every shift. The facility submitted a plan for removal of the Immediate Jeopardy on 8/2/22 at 12:58 PM that was not accepted. The facility submitted a second plan on 8/2/22 at 2:34 PM that was not accepted. On 8/2/22 at 4:30 PM the facility submitted a third plan of removal that was accepted on 8/2/22 at 5:00 PM. After determination of Immediate Jeopardy concerns, an extended survey was conducted. The Immediate Jeopardy was removed on 8/5/22 at 3:40 PM after validation that the plan had been implemented. After removal of the immediacy, the deficient practice continued with a scope and severity of E with potential for more than minimal harm for the remaining residents. The facility's removal plan included the following provisions: The elopement and wandering policy was reviewed and revised. All residents in the building were reassessed for elopement risk and if they were deemed a risk, interventions were put into place. Audits of MDS assessments to ensure the care plan reflected the needs/concerns identified. All staff and new hires received education on wandering, elopement, and resident safety. A Quality Assurance Performance Improvement (QAPI) Project was implemented to review and interpret all audit findings. The facility placed Pink Elopement Binders on each nursing unit at the nurse ' s station, in the conference room and at the front desk. The binders will be checked at the beginning of each shift and as changes occur. Completion of the task will be signed off on a signature sheet. Signs were placed on the door to alert staff and family members not to allow anyone to exit the facility without approval from licensed staff. Employees were made aware to monitor their surroundings when entering and exiting the facility and monitor that residents at risk for elopement do not exit the facility. Education that employees must respond to alarms as soon as possible, in a timely manner to prevent elopement. Employees have read and received a copy of the elopement policy. A process was put in place for agency staff to be educated on elopement prevention prior to taking an assignment. 2) Facility staff failed to ensure Resident #17 received protective devices that were intended to protect the resident from injury due to a fall. On 7/22/22 at 2:10 PM Resident #17's medical record was reviewed and revealed Resident #17 was admitted to the facility in December 2018 with diagnoses including but not limited to early onset Alzheimer's disease. Review of progress notes documented that Resident #17 had falls on 12/23/21, 2/10/22, 4/12/22, and 5/11/22 without injury. Review of progress notes documented on 5/18/22 at 13:58 (1:58) PM that hipsters were provided on 5/17/22. Hipsters are briefs that have impact absorbing pads over the critical hip area that are designed to minimize potential damage, including hip fractures that can occur from a fall. Review of Resident #17's care plan, had an actual fall with no injury r/t poor balance and poor communication/comprehension, had the intervention, apply hipsters at all times, which was initiated on 8/20/21. On 7/25/22 at 11:42 AM observation was made of Resident #17 in bed. Resident #17 was not wearing hipsters. On 7/25/22 at 3:08 PM Resident #17 was observed again in his/her room without hipsters. An interview of GNA #66, a GNA from a staffing agency, was conducted and she was asked if Resident #17 was wearing hipsters. GNA #66 stated, I didn't know [he/she] wore them. I didn't see anything in the room. The DON was informed on 8/9/22 at 11:20 AM.

Based on a facility-reported incident, closed clinical record review, staff interview, and reviews of the facility abuse policy, it was determined that facility staff failed to ensure a resident was free of staff abuse. This was evident for 2 (Resident #204, #412) out of 8 residents reviewed for abuse during an annual recertification survey. This deficient practice caused harm to Resident #204. The findings are: 1) A review of facility-reported incident MD 900 on 7/25/22 revealed that the facility reported an allegation of staff to resident abuse on 08/03/2020 in which the resident was observed with a bloody nose and a bleeding area to the resident's right lower leg stump. The facility also reported that the local police were notified and conducted an onsite investigation. The resident's physician and responsible party were also made aware of the allegations. A review of the facility's Abuse, Neglect, and Exploitation policy on 07/25/22, revealed an implementation and revision date of 07/21/2021, which defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. A review of the 8/3/2020 12:30 PM, nurses note revealed, Called to resident 204's room because s/he was sliding out of the wheelchair. Went to get assigned GNA #87 to help pull Resident #204 up in the chair. As soon as assigned GNA #87 came into resident 204's room Resident #204 began to cry and said, ' get him/her out of here s/he hit me all in my face. ' Assigned GNA #87 then stated that Resident #204 hit him/her in the face. Resident #204 stated, shut up and Assigned GNA #87 stated no I don't have to shut up and became argumentative. GNA #87 was asked to leave Resident #204 ' s room and s/he stated, I'm leaving anyway. GNA #87 left the room and went downstairs. Upon assessment Resident #204 had a nosebleed and skin tear on right stump. Treatment orders were put into place and the nurse practitioner (NP) was made aware. The NP did come in and assess Resident #204 on 08/03/2020. Resident #204 was reassured by staff that GNA #87 would not return to his/her room. A review of Resident #204 ' s physician note, dated 08/03/2020, revealed Resident #204 ' s physician was called to see a patient crying with a bloody nose and a skin abrasion to his/her right lower extremity stump. Resident #204 ' s physician documented that there had been an argumentative episode between the patient and a GNA (geriatric nursing assistant). Resident #204 ' s physician documented that Resident #204 Right Stump was observed with an abrasion with bleeding. A review of the facility investigation on 07/25/2022 revealed a statement by the facility social worker on 08/03/2020 regarding the alleged staff to resident abuse. The facility social worker indicated in his/her 08/03/2020 statement that s/he was alerted by Resident #204 calling out for help from his/her room. The facility social worker indicated that Resident #204 appeared to be falling out of his/her chair. The facility social worker and another staff person went in to assist Resident #204 and this is when the facility social worker indicated Resident #204 began to cry. The facility social worker also indicated this is when s/he observed that Resident #204 ' s stump was bleeding. The other staff person brought GNA #87 into the room and s/he and Resident #204 began an argumentative discussion. GNA #87 was then asked to leave Resident #204 ' s room. Other staff members came in to assist Resident #204 and proceeded to clean him/her up. The facility social worker indicated Resident #204 continued to cry during care. The facility social worker also handed Resident #204 a tissue. When Resident #204 blew his/her nose, blood was observed coming out of Resident #204 ' s nose. In an interview on 7/25/22 at 3:47 PM, with the Assistant Director of Nurses (ADON) the ADON stated that at the conclusion of the investigation, s/he substantiated the allegation of abuse to Resident #204 on 08/03/2020 by GNA #87. The ADON stated that GNA #87 was hyper after the incident with Resident #204. The ADON stated that GNA #87 stated to her/him that if someone hits me, I am going to hit them back. The ADON stated that he/she went and spoke with Resident #204 and observed Resident #204 nose was bleeding and there was an injury on his/her right knee stump. Resident #204 went on to inform the ADON that GNA #87 was rough and punched him/her on 08/03/2020. The ADON stated that s/he believed Resident #204, and documented the allegations in the report to the State Survey Agency, that GNA #87 abused Resident #204 during care on 08/03/2020. The ADON stated that the facility implemented the following: the alleged employee, GNA #87, was immediately removed from staffing on 08/03/2020, the facility immediately started an investigation and reported the incident to the State Survey Agency, and the local police were then notified of the incident. GNA #87 was terminated and reported to the Maryland State Board of Nursing. 2) Review of complaint MD 788 on 8/6/22 at 2:00 PM revealed Resident #412 reported that [he/she] asked if someone could transport [him/her] back to [his/her] room once therapy was finished. Resident #412 reported that the staff person said, you'll be alright. Resident #412 stated, how do you know how I feel? Resident #412 stated the staff person said, I hope you get ten of your toes cut off. Resident #412 stated, I felt some kind of way about what she said. Resident #412 stated, her comment affected me emotionally because she expressed how she felt about me. Resident #412 stated, I felt she was insensitive because I am currently dealing with possible amputations. Review of Resident #412's medical record on 8/6/22 at 2:00 PM revealed Resident #412 was admitted to the facility in July 2021. Review of a CRNP (Certified Registered Nurse Practitioner) note dated 7/16/21 documented that Resident #412 presented to the hospital with fever, chills, and worsening pain around a non-healing diabetic ulcer on the sole of the left foot. After an MRI at the hospital showed evidence of acute/chronic [CONDITION(S)], podiatry recommended amputation of all toes versus some toes. Resident #412 decided against amputation and said, only agrees to IV antibiotics at this time and does not want to take the risk of amputation of toes. Resident #412 was discharged from the hospital to subacute rehab for IV antibiotic management and physical therapy. [CONDITION(S)] is inflammation/infection of the bone. On 8/8/22 at 11:40 AM an interview was conducted with Staff #45 (director of Rehabilitation). Staff #45 stated that Resident #412 was able to get around independently in the wheelchair and would go from his/her room to smoke and through the halls. Staff #45 stated that Resident #412 was inappropriate with one of the rehab techs previously and the resident asked that tech to take the resident back to his/her room. Staff #45 stated, the tech was uncomfortable doing that. Staff #45 stated a physical therapy assistant stepped in and said, you can take yourself. She said jokingly, why don't you cut it off. He/she (Resident #412) was subconscious about it. I explained that while it was inappropriate, she said it was a joke and didn't mean it. I'm not condoning what she said, it was wrong. I did report it to the Nursing Home Administrator (NHA), and he did an investigation. We all had to write statements about everything. On 8/8/22 at 1:49 PM a review of employee statements obtained from the Nursing Home Administrator (NHA) for the incident that happened on 7/23/21 with Resident #412 revealed a written statement from PTA #46 (physical therapy assistant) that documented, The rehab tech stated to myself and [name], [Resident name] makes me uncomfortable; I don't like [him/her], I don't want to be around [him/her]. The statement continued, attempted to grope me yesterday. Once the resident's occupational therapy session was completed, he/she looked at the rehab tech and stated, my foot hurts, I can't wheel myself. Knowing the information the tech had provided previously, I stated, I think you'll be fine since both legs were on leg rests and he/she was using his/her arms to propel his/her wheelchair and had done so throughout the entire day without incident. Resident proceeded to get increasingly irate shouting, you think I'll be ok? You think? How dare you think you know how I feel. I just finished a workout, and my shoulders could be hurting, you don't know. At this point I said, well then if you can't use your arms and legs anymore, they can just cut them off and get rid of them, sarcastically since the resident could in fact propel him/herself around the facility at will. Since I was aware of how the resident was behaving towards our rehab tech, I did not want the resident to have access to her in a situation where he/she could continue to take advantage and make her uncomfortable. On 8/22/22 at 2:07 PM an interview was conducted with the PTA #46. PTA #46 stated that they were in the rehab gym and Resident #412 made comments towards the tech that made her uncomfortable. Resident #412 was trying to get the tech to wheel Resident #412 back to his/her room and Resident #412 was able to propel the wheelchair independently at that time. I told [him/her] [he/she] could wheel [him/herself] back because [he/she] was independent. PTA #46 stated that Resident #412 became agitated, and sarcastically I said if you are not going to use your arms and legs you might as well cut them off. I meant it not literally. The surveyor asked PTA #46 if she knew what Resident #412's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . PTA #46 stated, I had sensitivity training in-service. I did not get written up. They had a discussion that it was an inappropriate comment. Discussed with the Director of Nursing on 8/9/22 at 11:20 AM.

Based on medical record review and interview with facility staff, it was determined that the facility failed to, 1. Thoroughly complete abuse investigations, 2. Provide education to staff after allegations of abuse were made, 3. Protect residents after the report of an alleged abuse, 4. Ensure that a resident was free from abuse and injury (#1). This was found to be evident for 3 out of 31 residents (#89, #95, and #1) reviewed during stage two of the survey. On August 11, 2017 at 4:32 PM an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to have a system in place to thoroughly complete investigations into allegations of abuse, protect residents and to provide education to staff after an allegation of abuse was made. The initial plan to remove the immediacy was given to the survey team (State Surveyors #1, #2 and #3) at 7:25 PM. This plan was not accepted by the survey team and the Office of Health Care Quality. At 8:00 PM another plan to remove the immediacy was given to the survey team and reviewed by the Office of Health Care Quality. After modifications another plan to remove the immediacy was given to the survey team at 8:58 PM. The plan was carried out and the Immediate Jeopardy was removed on 8/11/17 at 9:00 PM. After removal of the immediacy, the deficient practice continued for an actual harm deficiency due to findings of Example #3, at a scope/severity of G level for the remaining residents. On 7/1/17 the facility changed ownership and new abuse policies and procedures were put in place, however as of time of the immediate jeopardy all staff had not yet been in-serviced regarding the new abuse policies and procedures. The findings include: 1. On 8/11/17 review of Resident #89's medical record revealed [DIAGNOSES REDACTED]. Additional review revealed a Brief Interview Mental Status (BIMS) completed on 4/26/17 with a score of 15/15, meaning the resident is intact cognitively. Review of the facility reported incident MD 01, investigation documentation revealed that on 5/26/17 Resident #89 reported to the previous Administrator (NHA #2) that on or about 5/23/17 or 5/24/17 s/he had been called a derogatory name by (name of employee) (Staff Nurse #2) and that same nurse had, with her hands, made a fist pounding it into her other hand as if to threaten to hit her/him. The nurse was reported as suspended pending investigation that was initiated on 5/26/17. Review of the residents medical record on 8/11/17 revealed a nursing note from 5/26/17 at 1:30 PM that Resident #89 was alert and oriented x3, was crying and upset about nurse mistreatment that occurred previously on 5/23/17 or 5/24/17 on the 3 PM -11 PM evening shift. The note said the resident requested to speak to the Administrator (NHA #2) and the Unit Manager. The nursing note was updated at 2:00 PM to include that the police were called by the resident to file a complaint of being unsatisfied with service given. On 5/26/17 Resident #89 was ordered a psychiatric consult related to emotional support related to an abuse complaint. This consult was followed-up on 5/31/17 and the Licensed Psychologist noted the following: Specific issues: adjustment related anxiety, multiple medical problems; Additional Information/Recommendations: reported poor appetite for facility food (loss of weight this week) Wounds are better per (his/her) report. Will follow-up. The psychiatric Nurse Practitioner also saw the resident on 5/31/17 and documented the following: For rep Pt reports that staff are not pleasant; Chief C/O (complaint): adjustment, [MEDICAL CONDITION]; Concerns/Findings: (She/He) to stay here. 'I want that people respect me.' Pt does not want any psych meds at present time. There was no documentation found in either note addressing the specifics of the complaint made by Resident #89 to the facility, therefore it is unclear if the Licensed Psychologist and psychiatric Nurse Practitioner were made aware of these concerns so they could be addressed. Per the facility reported investigation, the employee was suspended on 5/26/17. Review of Nurse #2's time card revealed that she returned to work on 6/2/17 and clocked in at 11 PM, after the facility reportedly completed their investigation. Review of Nurse #2's file and the facility investigation revealed that the facility failed to provide education or abuse training regarding the alleged abuse that occurred around 5/23/17 until 6/12/17. Nurse #2 was noted to continue to work in the facility without receiving additional training regarding abuse until 6/12/17. The Director of Nursing (DON) was interviewed on 8/11/17 10:26 AM regarding the lack of training and she had no further information. At 2:00 PM she verbalized that she had no further information into the investigations. She stated that she was sure further investigations and interviews were completed but was unable to locate them at this time. She also indicated that she had no further information regarding the police being contacted by Resident #89, if they came to the facility or what their findings were. On 8/11/17 at approximately 2:00 PM review of scheduling sheets revealed Nurse #2 had worked the night shift on 8/6/17, 8/7/17, 8/9/17, 8/10/17 and was scheduled to work the night shift on 8/11/17 starting at 11:00 PM. Further review of the final report submitted to the state agency revealed that the facility was unable to substantiate an allegation of abuse as there were no witnesses. It further noted that although Resident #89 was deemed capable and had a BIMS of 15 showing s/he was cognitively intact they documented that s/he was manipulative. Further review of the investigative findings revealed that the resident reported various versions of events to staff. Review of the investigation provided to the survey team did not reveal multiple documented statements from Resident #89 regarding the allegation of abuse. A review of Resident #89's care plan failed to reveal any documentation or care plan regarding manipulative behaviors prior to 6/2/17, after the allegation of abuse occurred. A care plan regarding impaired or inappropriate behaviors related to ineffective coping skills as evidenced by telling different versions of events to different individuals was developed on 5/28/17. The goal for the resident to have less manipulative behaviors was initiated on 6/2/17, although there were no specific manipulative behaviors identified for the staff to monitor. Interview on 8/22/17 at 9:40 AM with the DON revealed that the resident had been non-compliant when it came to physician orders, such as maintaining a fluid restricted diet, but nothing else in the resident's history alerted her regarding false allegations toward staff. Further interview on 8/22/17 at 9:45 AM with the facility DON regarding the investigation revealed that she felt they (the facility) did a thorough investigation at the time and although, per the documentation, they were unable to substantiate the allegation of abuse as there were 'no witnesses,'. She indicated that she and the Administrator (NHA #2) did not feel that Nurse #2 should remain as an employee in the facility, although Nurse #2 did continue to work and was assigned to the resident that made the allegation of abuse against her. Review of staffing sheets revealed that Nurse #2 was assigned to Resident #89 upon her return to work and would continue to be assigned to the resident throughout the remainder of the residents stay in the facility which ended in the middle of June 2017. Review of the Resident #89's psychiatric and psychology notes from visits that occurred after the incident, noted that s/he wanted to be respected and that the staff were unpleasant. There was no documentation of follow up with the resident to see if s/he felt safe and comfortable in the nursing home and staffing environment. Further review of the Nurse #2's employee file revealed that secondary to concerns voiced by employees and managers, the employee 'has a negative attitude and display less than optimal customer service skills.' Additionally, it was noted that a 'Resident (unidentified) verbalized a feeling of discomfort with employee in regard to their continued negative interactions.' An EAP (employee assistance program) was recommended by the DON in the presence of Human Resources (HR) at that time on 4/25/17, however, the employee refused and further gave a verbal and written resignation of her position as a unit manager effective in 2 weeks (on 5/9/17) and will assume position of a staff nurse. During an interview with Staff Nurse #3 on 8/11/17 at 3:20 PM revealed that Nurse #3 had multiple interactions with Nurse #2 and she was noted as short with Nurse #3 and continued to be 'loud' with the residents. These findings were reported to the Administrator and Chief Nurse (corporate nurse) on 8/11/17. Interview with the DON on 8/22/17 at 9:40 AM revealed even though Nurse #2 continued to work in the facility after the allegation of abuse, the DON would come in early and follow up with staff that worked with Nurse #2 to see if any further issues or concerns arose. She would also review Nurse #2's nursing notes to see if there were anything concerning. The DON did report that she had to call Nurse #2 on at least one occasion to review a resident's care plan as what was documented did not reflect the resident's needs. Further review of Nurse #2's employee file revealed that she had previous training on abuse on multiple occasions, including as recent as 3/2/17, but no retraining was noted after the incident until the employee had already returned to work. While the facility did not substantiate the allegations of abuse, according to the employees file this was not the first time Nurse #2's behavior towards residents was brought to her and the management's attention. Nurse #2 did not receive re-training until 6/12/17, although abuse training was provided by the facility for all staff starting on 6/2/17. The training the employee received was also regarding reporting abuse, not on the concern as to which she was suspended and the allegation was about. It was noted that Nurse #2 was assigned to Resident #89 upon her return to work and would continue to be assigned to the resident throughout the remainder of the residents stay in the facility which ended in the middle of June 2017. Review of the Resident #89's psychiatric and psychology notes from visits that occurred after the incident, they noted that s/he wanted to be respected and that the staff were unpleasant. There was no documentation of follow up with the resident to see if s/he continued to feel safe and comfortable in the nursing home and staffing environment after 5/26/17. 2. Review of Resident #95's the medical record on 8/11/17 at 2:39 PM revealed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #95 was receiving [MEDICATION NAME] (an antidepressant) for appetite. Resident #95's BIMS score was assessed as 15/15 on the 5/25/17 Minimum Data Set (MDS) assessment. Review of the facility investigation documentation for facility reported incident MD 627 revealed that on 5/30/17 residents were being interviewed, Has staff here abused you? Resident #95 responded, 'yes sometimes when staff members are taking care of me they can be too rough. When I ask them to slow down they say it's just my job, i'm just (not legible) to change you. The employees name is (GNA (geriatric nursing assistant) Staff #4). This happened when I was in (room number). On 5/30/17, a psych evaluation was ordered for Resident #95 along with treatment for [REDACTED]. Review of the 5/31/17 psych note revealed the following, 'due to severe weakness not able to (not legible) testify for depression. The pt (patient) wants to eat better suggest to Increase [MEDICATION NAME] Refuse to see a psychologist. Recommended increase in [MEDICATION NAME] from 7.5 to 15 mg.' Review of the Witness Statement, signed on 5/31/17 by GNA #4 and the Director of Nursing (DON), revealed that the DON asked the GNA about any negative interactions with residents, and if anyone had complained about rough care. The GNA stated no. At the end of the form the following statement was found, Employee was made aware of what the accusation was, and the resident's name was not disclosed. Further review of the facility investigation failed to reveal documentation of a follow-up interview with the resident, although the report sent to the Office of Health Care Quality (OHCQ) referenced that a conversation occurred between the DON and the resident in which the resident stated that it may not be abuse but that s/he does not like the above GNA because she just moves so fast and does not smile. On 8/11/17 at 2:00 PM the DON reported that there should have been follow up interviews. Further review of the facility investigation failed to reveal a date when the investigation was completed. On 8/11/17 at 3:25 PM the DON confirmed that there was no additional documentation found regarding this investigation and no evidence of the date the completed investigation report was sent to OHCQ. The report to OHCQ stated that the allegation of abuse could not be substantiated and that GNA #4 received Customer Service Education. On 8/11/17 review of the GNA #4's employee file revealed documentation of abuse training in August 2016, and training on 6/6/17 for Customer Care: How to enhance your service skills. GNA #4 had been employed at the facility since April of 2014 but there was no evidence of an annual performance review within the past year. On 8/14/17 the DON reported that GNA #4 was suspended until 6/6/17, the day she came in for training only. The DON also reported that GNA #4 returned to work on 6/7/17 but failed to clock in or out on the Timecard for that day. On 6/7/17 GNA Staff #4 was involved in an abuse incident with Resident #1 that was substantiated and the GNA was terminated. (See example 3). 3. Resident #1 was admitted to the facility in April 1998 with [DIAGNOSES REDACTED]. On 6/7/17 Housekeeping Employee #10 reported to his/ her supervisor and the Director of Nursing a witnessed incident of alleged physical abuse carried out upon Resident #1 by Geriatric Nursing Assistant (GNA) #4 that occurred between 11:00 AM and 1:00 PM. The facility investigation documentation contained the witness account, detailed below: The GNA (Geriatric Nursing Assistant) came in the room and the patient was in the wheelchair and the GNA was pushing the patient in the room, but (GNA #4) was pushing him/her so harsh, and tried so hard to push the patient in the room, the patient was like jerking. I thought the wheelchair was going to fall forward. I thought that (GNA #4) was going to push (Resident #1) out of the chair. The patient's feet were bent and twisting. You could see that the patient was hurt. And then (GNA #4) just pushed (Resident #1) in and the patient's shoes came off. The GNA kicked the shoes into the room and slammed the door. You could tell the GNA was very angry. The patient was screaming and crying. On 8/10/17 at 11:25 AM an interview was conducted with Housekeeping Employee #1 who recalled the incident as follows: it was an experience, (GNA #4) was just pushing (Resident #1), it looked like the chair was falling forward, the resident's foot was like bent, it just scared me so bad because his/her foot was bent back and Resident # 1 was screaming and the GNA did it about three to four times and just pushed the resident in the room, the wheelchair hit the bed, and the GNA slammed the door and kept going. I then went straight to my supervisor and let him/her know and one of the girls I work with. The physician was notified of the incident by nursing staff on 6/7/17. The following orders were entered into the medical record: -6/7/17 at 3:16 PM 1: Psychiatric consult for emotional support; -6/7/17 at 4:30 PM: X-ray of bilateral foot and ankle 2 views to r/o (rule out) fracture. Review of the medical record revealed that an X-Ray / Radiology report for Resident #1 was received on 6/7/17. The report found no issues with the left foot. The right ankle x-ray/radiology report read: Findings: the ankle mortise is preserved without fracture or dislocation. There is ankle soft tissue swelling. No foreign body is seen. Impression: Ankle swelling but no fracture. A nursing note entered into Resident #1's medical record on 6/7/17 at 3:45 PM read: Resident sitting up in the wheelchair this shift. Several crying episodes. PRN (as needed) [MEDICATION NAME] given with little effect. [MEDICATION NAME] is a medication used to treat anxiety. A Nurse Practitioner's Progress Note entered into the medical record on 6/8/17 revealed the addition of a [DIAGNOSES REDACTED]. On 6/12/17 a psychiatric consultation was conducted with no new issues noted for Resident #1 and no new orders initiated. The facility initiated an investigation on 6/7/17 and reported the incident to the Office of Healthcare Quality. GNA #4 was suspended pending investigation into the matter. The facility led investigation substantiated that abuse occurred and terminated the employee. The employee was not reported to the Board of Nursing. In interview on 8/10/17 at 11:55 AM the Director of Nursing (DON) stated, I don't know why they did not report her. The previous owners did not want to. They didn't give me a real reason but they mentioned they were fearful of union retaliation. On 8/10/17 at 12:00 PM the findings were discussed with the DON and it was confirmed that facility staff failed to ensure that Resident #1 was free from abuse and injury. As a result of these investigations and the findings listed above, on August 11, 2017 at 4:32 PM an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to have a system in place to thoroughly complete investigations into allegations of abuse, protect residents and to provide education to staff after an allegation of abuse was made. The initial plan to remove the immediacy was given to the survey team (State Surveyors #1, #2 and #3) at 7:25 PM. This plan was not accepted by the survey team and the Office of Health Care Quality. At 8:00 PM another plan to remove the immediacy was given to the survey team and reviewed by the Office of Health Care Quality. After modifications another plan to remove the immediacy was given to the survey team at 8:58 PM. The plan to remove the immediacy included, but was not limited to: 1. LPN #2 was removed from the facility schedule and was informed to return to the facility on Monday August 14, 2017 to meet with the Nursing Home Administrator (NHA). Employee will not return to patient care. 2. Facility residents with a BIMS of 8 or greater were interviewed to determine if there were any current concerns regarding safety. Resident with BIMS of 7 or less have had skin assessment by a licensed nurse. Any identified concerns would be investigated and reported as required. QA audit will be completed on the last 30 days of concerns to evaluate if any concern met the definition of a reportable incident. 3. Staff present in facility were educated with the (new ownership name) abuse policy and acknowledgement statement. Ongoing education to ensure 100% of current facility staff to be educated on the (new ownership name) abuse policy. Staff will be provided this education before they will be permitted to provide any further resident service. The NHA will review and compare the employee listing to the documentation of completed in-services to ensure 100% of current employees are educated. 4. Ongoing QA monitoring will be completed by the NHA to validate that incidents and allegations have been properly investigated and that actions have been taken to safeguard the residents. Residents will be monitored by social services weekly for 4 weeks after allegation with respect to psychosocial wellbeing. Any employee that remains employed after an allegation of abuse will be monitored by the NHA or DON weekly for 1 month and then quarterly times three to ensure no trends are identified by repeated concerns. The plan was carried out and the Immediate Jeopardy was removed on 8/11/17 at 9:00 PM. After removal of the immediacy, the deficient practice continued for an actual harm deficiency due to findings of Example #3, at a scope/severity of G level for the remaining residents. On 7/1/17 the facility changed ownership and new abuse policies and procedures were put in place, however as of the time of the immediate jeopardy all staff had not yet been in-serviced regarding the new abuse policies and procedures.

Based on medical record review and staff interview, it was determined the facility staff failed to: appropriately treat and manage a resident's pain as directed by physician order. This was evident for 1 of 17 residents (#17) reviewed during a complaint survey. The findings include: Review of the medical record for Resident #17 on 1/12/17 revealed multiple comorbidities including; systemic lupus (an [DIAGNOSES REDACTED] disease where the body's immune system mistakenly attacks healthy tissue), right shoulder [MEDICAL CONDITION]-status [REDACTED]. Review of the hospital discharge records revealed that the resident had a recent history of requiring intravenous pain medication intervention to achieve pain relief. The resident was weaned to oral pain medication and discharged to the facility. Further review of the medical records on 1/12/17 revealed that the resident was admitted to the facility in September for rehabilitation. Further review of the medical records revealed a physician order [REDACTED]. diagnosed pain and discomfort. Review of the residents Medication Administration Record [REDACTED]. During that time frame (day of admission and 3 days post) the prn [MEDICATION NAME] was administered 5 times for complaints of pain. Further review of the MAR indicated [REDACTED]. Review of the resident's medical record failed to reveal documentation that the resident's physician was notified that the resident's scheduled pain medication, [MEDICATION NAME] and [MEDICATION NAME], were unavailable for 3.5 days. Further review of the resident's pain flow record only revealed documentation of pain scoring on 9/5/16 and 9/16/16 with documentation of [MEDICATION NAME] administration on those 2 days with pain scores of 10 and 6 with post-medication administration follow up pain scores of 7 and 4 respectively. Further review of the medical record revealed that on 9/21/16 the resident had increased complaints of pain. The prn [MEDICATION NAME] was administered at 6:00 AM and 2:00 PM on 9/21/16. A nursing note from the 7 AM - 3 PM shift noted that the resident was in complete pain throughout the shift and even refused care because his/her pain level was a 9/10. The resident was documented as crying and yelling. Review of the MAR indicated [REDACTED]. Review of the documentation for the 3 PM -11 PM shift on 9/21/16 revealed documentation that the resident continued to state his/her pain was a 10/10 and continued to refuse care secondary to the pain. The on-call physician was notified and order received to send the resident to the emergency room via 911 for uncontrolled pain. Resident #17 left facility at 6:00 PM. Review of the MAR indicated [REDACTED]. The findings were reviewed with the facility Director of Nursing, in lieu of the Administrator's absence, prior to exit on 1/13/17. No further documentation was provided to the survey team prior to exit.

Based on record review, observations, and interview with staff, it was determined that the facility staff failed to use the proper accessory (body sling) for a mechanical lift device which resulted in the resident sustaining a fractured left distal femur requiring closed reduction repair and placement in a long leg cast. This was evident for 1 of 17 residents (#16) reviewed during a complaint survey. The findings include: Review of an anonymous complaint received by the State Agency revealed allegations that Resident #16 had sustained a fall from the improper use of a mechanical lift by the facility staff. On 01/12/17 Resident #16's medical record was reviewed. This review revealed that the resident was [AGE] years old and had [DIAGNOSES REDACTED]. The resident had a care plan initiated on 8/16/16 for activities of daily living (ADL) Functional/Rehab Potential with interventions requiring total dependence for ambulation and transfers. Review of the resident's Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent and required two person assistance with transfers. The MDS is a standardized multi-disciplinary assessment tool used to assist in the planning of resident care. Review of the facility's incident report documentation revealed that on 9/13/16, two GNAs (geriatric nursing assistants), with the use of a mechanical lift device, were transferring the resident from his/her bed to a chair when the resident began to slide out from the sling onto the floor. The resident complained of left knee pain and an x-ray was ordered. The radiology report results indicated a fracture of the distal femur with a medium lateral displacement of the distal fragment. The resident was subsequently transferred to the hospital where the fracture was reduced and a long leg cast was placed. The resident returned to the facility on [DATE]. The facility filed a Comprehensive and Extended Care Facilities Self-Report to the OHCQ on 09/20/16. Interview with the Corporate MDS Nurse (Staff #4) on 01/13/16 revealed that upon further investigation and interviews, the facility concluded that the GNAs were using mechanical lift slings that were procured from a nearby hospital. The facility acknowledged that the use of the inappropriate slings and lack of safety awareness by the staff contributed in Resident #16's fall. The findings were reviewed with the facility Director of Nursing, in lieu of the Administrator's absence, during the exit conference on 1/13/17.

Based on administrative and medical record review and staff interviews it was determined the facility failed to: 1) provide ongoing supervision of Resident #19 after he/she was found to have inappropriately touched a resident (Resident #20) in the private area; 2) ensure the safety of a cognitively impaired resident (Residents #20) after he/she was inappropriately touched by Resident #19; and 3) conduct a thorough investigation of an incident of resident to resident sexual abuse. This was evident for 2 of 22 residents reviewed during this investigation. Based on the findings, related to complaint MD 157, on 9/12/16 at 4:30 PM, an Immediate Jeopardy was identified. The facility submitted an acceptable plan of removal to the State Survey Agency on 9/12/16 at 6:34 PM and it was accepted. After removal of the immediacy, the deficient practice continued with the potential for more than minimal harm with a scope/severity of D level for the remaining residents. The findings include:The Minimum Data Set (MDS) is a comprehensive multi-disciplinarian assessment of the resident completed by the facility staff. The MDS is a tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed.1) Review of a complaint (MD 157) on 9/12/16 revealed an allegation that Resident #19 was fondling residents. Interview with facility staff revealed an incident form was generated by Staff #1 after he/she observed Resident #19 touching Resident #20 in the private area on 7/10/16. Resident #19 was admitted to the facility for long-term care with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed facility staff entered a BIMS score of 15 for this resident. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive understanding. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. It is also noted the resident self-propels in a wheelchair throughout the facility as desired.Medical record review failed to reveal a re-evaluation of Resident #19's physical and mental status after the incident despite documentation that this behavior had not occurred in the past. Medical record review also revealed a care plan was initiated on 7/11/16 that contained an intervention to observe the Resident #19 every 15 minutes for 30 days. During interview with Staff #12, he/she stated there was no documentation the every 15 minutes observations occurred and he/she didn't recall the incident. Review of the medical record failed to reveal any documentation of the every 15 minute observation rounds. At the time of the survey the resident was observed self-propelling his/her wheelchair throughout the facility.The facility failed to provide evidence that adjustments were made to the Resident #19's level of supervision after he/she was observed inappropriately touching Resident #20 and the facility failed to provide evidence that facility staff maintained 15 minute observation intervals for this Resident as noted in the care plan initiated after the incident, on 7/11/16.2) The facility failed to ensure the ongoing safety of Resident #20 after he/she was inappropriately touched by Resident #19. Review of a complaint (MD 157) on 9/12/16 revealed a complaint that Resident #19 was fondling residents. Staff interview revealed that on 7/10/16 Staff #1 observed Resident #19 touching Resident #20 in the private area.Resident #20 was admitted to the facility for long-term care with [DIAGNOSES REDACTED]. Review of a quarterly MDS Assessment completed on 6/14/16 revealed facility staff coded the resident in Section C Cognitive Patterns Section C1000 Cognitive Skills for Daily Decision Making as 2 (moderately impaired- decisions poor; cues/supervision required. The resident is noted to ambulate freely throughout the facility. Review of the incident reports and medical record revealed Resident #19's physician was made aware of the incident on 7/10/16. No new orders were given. Medical record review and staff interview failed to reveal evidence that Resident #20's care plan was adjusted to reflect the need for increased supervision or other interventions to maintain the resident's safety from Resident #19 and any further sexual abuse. 3) The facility failed to conduct an investigation of this incident or report it to the Office of health Care Quality. Medical record review and staff interview failed to reveal interviews with other residents and staff to determine if this was an isolated incident, staff education regarding investigating and reporting abuse, and a plan to monitor the residents to ensure their ongoing safety.Because of these systems failures, an immediate jeopardy was called at 4:30 PM on September 12, 2016 by the Office of Health Care Quality. The plan to remove the immediacy included the following: one-on-one supervision of Resident #19, updating Resident #20's care plan, review of all incidents from the past 30 days by the Administrator and Director of nursing to ensure proper reporting and investigation occurred, review of alert and oriented residents for any history of sexual behavior, and re-education of the facility staff. The plan to remove the immediacy was submitted to the State Agency and accepted at 6:34 PM on September 12, 2016.

Based on medical record review and staff interviews it was determined the facility failed to implement an effective system where all staff knew their responsibilities for managing patients during cardio-pulmonary events when 1) ,[DATE] staff interviewed were unable to state how to determine and confirm code status in accordance with facility policy, 2) when staff violated the rights of Resident #1 by performing cardio-pulmonary resuscitation against the resident's known wishes without validating the resident's code status, and 3) when after the serious preventable adverse event performing CPR on Resident #1, the facility failed to promptly assess the event and institute corrective actions to ensure similar events would not recur affecting other residents. In addition, the facility failed to maintain a system to ensure licensed nursing staff maintain current CPR certification and documentation of certification is readily available. This was evident for 1of 5 residents (#1) reviewed during this revisit survey and placed all residents at increased risk for egregious violations of resident rights.Based on the findings on [DATE] at 3:30 PM, an Immediate Jeopardy was identified related to advance directives. The facility submitted a plan of removal to the State Survey Agency on [DATE] 5:51 PM, and it was not accepted. The facility submitted another plan of removal on [DATE] at 6:25 PM, and it was not accepted. The facility submitted a final plan of removal on [DATE] at 6:48 PM. The plan was reviewed and accepted by the surveyor on-site on [DATE] at 6:55 PM. After removal of the immediacy, the deficient practice continued with the potential for more than minimal harm with a scope/severity of D level for the remaining residents. The findings include: Medical record review revealed Resident #1 was admitted to the facility for long-term care and had [DIAGNOSES REDACTED]. Medical record review revealed two physician's certificates dated [DATE] and [DATE] that certified the resident as having an end stage condition. A characteristic of an end stage condition is that to a reasonable degree of medical certainty, treatment of [REDACTED].The resident's MOLST (Medical Order for Life Sustaining Treatment) was dated [DATE] and noted the Resident's code status as Do not Attempt Resuscitation (no CPR). The MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments based on a patient's wishes about medical treatments. Medical record review also revealed physician's notes dated [DATE] and [DATE] that noted the Resident's code status as, Do not Attempt Resuscitation (no CPR).Surveyor review of the medical record on [DATE] revealed a nursing note dated [DATE], written by Staff #1, that reported the resident was found unresponsive, lips purple and face with a blue hue. The writer reported the resident was not breathing and did not have a pulse. CPR was initiated by the writer and 911 was activated. The resident was transported to the hospital. A hospital Admission History and Physical Report noted the resident was transported to the hospital emergency department for further evaluation after an episode of pulselessness and the initiation of CPR. This document also noted the resident's code status was Do Not Resuscitate.In interview with the surveyor on [DATE] at 11:15 AM and 2:20 PM respectively, Staff #2 (medication aide) and Staff #3 (licensed practical nurse) were unable to state how nursing staff locate information regarding a resident's code status. Review of the facility's Cardiopulmonary Resucitation (CPR) policy, dated [DATE], revealed the facility required 2 staff to validate the code status. One of seven licesned staff interviewed on [DATE] stated this requirement.During an interview with the surveyor on [DATE] at 1:41 PM, the Director of Nursing (DON) stated he/she entered the room when the chest compressions were in progress and asked the nurse (Staff #1) performing CPR what the resident's code status was. The DON reported Staff #1 did not verify the resident's code status prior to initiating CPR. The Director of Nursing confirmed during the interview that facility staff were not re-educated regarding the policy and procedure for CPR following this incident and other resident's charts were not audited to ensure the appropriate code status was entered in the medical record. The surveyor inquired who in the facility was required to be CPR certified, and the DON responded all licensed staff and Certified Medication Aides. However, according to the facility policy, certification is only required for licensed staff.During an interview with the Nursing Home Administrator on [DATE] at 5:10 PM the surveyor requested documentation validating current CPR certification for all licensed staff. The Administrator stated the former Human Resources Director misplaced the CPR documentation and the facility just hired a new Human Resources Director. CPR certification for all licensed staff was not available for review.Due to these failures, an immediate jeopardy was called an Immediate Jeopardy was identified at 3:30 PM on [DATE] by the Office of Health Care Quality. The facility submitted a plan of removal to the State Survey Agency on [DATE] 5:51 PM, and it was not accepted. The facility submitted another plan of removal on [DATE] at 6:25 PM, and it was not accepted. The facility submitted a final plan of removal on [DATE] at 6:48 PM. The plan was reviewed and accepted by the surveyor on-site on [DATE] at 6:55 PM.The plan to remove the immediacy included the following: education of licensed staff related to advance directives and facility CPR policy, CPR verification via telephone for licensed staff, and review of MOLST forms for Resident #1 and all remaining residents in the facility.

Based on administrative and medical record review and staff interviews, it was determined the facility failed to provide on-going supervision to ensure the safety of cognitively impaired residents (Residents #2 and #3) who were assessed as elopement risks. In addition the facility failed to provide evidence that clear guidelines for the management and supervision of residents determined to be at risk for elopement were implemented. This resulted in Resident #2, who required daily monitoring and treatment for [REDACTED].#3 eloping from the facility on 8/21/15. This was evident for 2 of 5 residents reviewed during this investigation.Elopement is defined as a resident that is not pre-authorized to leave the agency or activity site, but does so intentionally and the resident's location is unknown.The Secure Care management system is utilized to protect residents, at risk for wandering and elopement. If a resident wearing a Secure Care bracelet signaling device passes through a monitored area, an alarm sounds to alert staff of a possible departure. The Wander Guard alarm will continue to sound until staff respond to the door to reset the alarm. The findings include:Review of a facility reported incident on 12/1/15 revealed Resident #3 eloped from the facility on 8/21/15, unobserved, despite having a Secure Care bracelet in place, being maintained on close observation at 15 minute intervals, and the presence of a receptionist to monitor the front entrance of the facility. The facility report also noted the facility's failure to investigate the cause of the Secure Care alarm during the time of the elopement.This [AGE] year old resident (Resident #3) was admitted to the facility on [DATE] for long-term care with a [DIAGNOSES REDACTED]. Prior to admission to the nursing home the resident was hospitalized after family noted a significant worsening in the resident ' s mental status. The resident improved while hospitalized but was noted to be in constant motion on the floor. A nursing admission note completed on 8/14/15 reported the resident's family member advised staff that the resident was actively exit seeking, wandered and was combative if his/her requests were not granted. Review of Resident #3's admission assessment revealed the facility failed to conduct an elopement risk assessment for Resident #3 upon admission on 8/14/15, as required by the facility's policy, despite receiving information from the resident's family indicating the resident was a high risk for elopement.A physician's orders [REDACTED].A nursing progress note completed on 8/19/15 at 5:30 PM reported the resident had to be escorted off of the elevator, twice, by a nurse and dietitian. It was also noted that the resident was very angry, exit seeking, resistive to care and packed his/her clothes, insisting on going home. The facility failed to provide evidence that immediate adjustments were made to the Resident #3's level of supervision, that an elopement care plan was implemented, or that an elopement assessment was completed even when the risk of elopement was heightened by the resident's attempts to leave the unit on 8/19/15.Medical record review revealed 15 minute resident safety check sheets that began on 8/21/15 at 3:00 PM. The facility failed to provide evidence that facility staff maintained 15 minute observation intervals for Resident #3 on 8/21/15 just prior to his/her elopement. Facility staff assigned to conduct the safety checks are to enter their initials on the form validating the resident's presence in the facility at 15 minute intervals. Review of the facility incident report, resident safety check sheet and staff statements indicated there was a lapse in supervision just prior to the resident eloping from the facility. Review of the facility incident report dated 8/21/15, indicated the receptionist (Receptionist #2) on duty at the time the resident eloped heard the Secure Care alarm and assumed it was triggered by a resident returning from an appointment and turned the alarm off. Review of the medical record and incident report revealed no other staff responded to the Secure Care alarm. Resident #3 exited the building unobserved and was later found at the convenience store across the street from the facility. During the investigation the facility provided a Quality Assurance Plan dated 8/21/15 regarding this incident. The plan entailed conducting random weekly reviews of 15 residents to include elopement assessments and care plans for appropriate interventions and conducting elopement drills monthly on each shift. The plan did not contain a target date for the completion of the monitoring and there was no evidence the plan was fully implemented. The surveyor requested the results of the chart audits but none were produced at the time of the survey. The plan also indicated education would be provided on Elopement/Missing resident protocols. Review of the facility policies failed to reveal procedures for staff response to the Secure Care alarm system. During an interview with the surveyor on 12/1/15 at 2:05 PM CMA #1 stated when the Secure Alarm system sounds, staff on the first floor or the receptionist are responsible for notifying staff on the second floor that the system is engaged.In interview with GNA #1 (the GNA assigned to monitor Resident #3 every 15 minutes) on 12/3/15 at 1:45 PM, he/she reported he/she last saw the resident at approximately 4:45 PM. He/she stated a nurse from the first floor summoned her/him to assist with locating another resident, thought to be missing, on 1 East (first floor). The GNA reported he/she returned to the unit after 5:00 PM whereupon staff asked him/her if she knew the whereabouts of Resident #3. It was not clear from the documentation that the resident was being monitored between the period 4:45 PM and 5:00 PM. The resident safety check sheet contained GNA #1's initials for the 5:00 PM observation however he/she confirmed he/she was not on the unit at 5:00 PM. The GNA also reported in his/her statement that the resident was found some time after 5:30 PM at the convenience store located across the street from the facility, which he/she confirmed in interview. When asked about staff's lack of response to the alarm, the GNA stated the Secure Care Alarm could not be heard on the second floor. When the alarm is triggered the receptionist or staff on the first floor should alert staff on other units that the alarm has been triggered.In interview with the Director of Maintenance on 12/3/15 at 1:35 PM, he/she confirmed that when the Secure Care system alarms it cannot be heard on the second floor. The location of the alarm registers on an enunciator which is located on the first floor unit, designated as 1 West. During the times that the receptionist is on duty he/she is responsible for notifying the units that the alarm has been activated. During times when the receptionist is off duty, the staff from the 1 West unit, are responsible for notifying other units that the alarm has been activated.Administrative and medical record review and staff interviews failed to reveal a thorough investigation of the systems failures that contributed to the elopement which included lack of staff response to the Secure Care alarm, the lapse in supervision, and lack of a timely assessment and implementation of a plan of care to manage Resident #3's risk for elopement.2. Surveyor review of a facility reported incident on 11/30/15 revealed Resident #2 who was determined, by the courts, to lack sufficient understanding or capacity to make or communicate responsible decisions concerning his person and property because of a disability (Schizophrenia) was transported to a medical appointment by a facility driver and dropped off in front of the medical facility without ensuring the resident had continued supervision. An Order Appointing Guardian of the Person and property, dated 7/22/15, found by clear and convincing evidence that the resident lacked sufficient understanding or capacity to make or communicate responsible decisions concerning his person and property because of a disability (Schizophrenia). The court further found the resident was unable to consent to the appointment of a guardian because he needed a guardian and no less restrictive form of intervention was available. A Hospital Discharge Summary dated 7/31/15 documented the resident was incompetent, per the psychiatrist's evaluation and two physicians completed certificates of incapacity to make informed decisions dated 7/31/15 and 8/26/15 respectively. The resident was admitted to the facility on [DATE] post hospitalization for chronic foot ulceration, cellulitis and abscess of both lower extremities and the debridement and removal of the 5th metatarsophalangeal joint secondary to osteo[DIAGNOSES REDACTED]. The resident was receiving antibiotics via a central venous catheter for sepsis. Per the physician's order [REDACTED]. A central venous catheter is a catheter placed into a large vein in the neck, chest or groin and is used for the administration of medications or fluids. [DIAGNOSES REDACTED]. (conditions that involve delays in the development of many basic skills, most notably the ability to socialize with others, to communicate, and to use imagination). Further medical record review on 11/30/15 and 12/1/15 revealed an Elopement Risk Evaluation completed on 8/21/15 determined the resident was at risk for elopement as evidenced by exit seeking behavior, lack of awareness of safety needs and poor decision-making skills. A Secure Care bracelet was ordered for the resident on this date to address the risk of elopement. Physician's notes dated 8/24/15 and 8/26/15 documented an ongoing pattern of refusal of medications, blood sugar monitoring and wound treatment. The physician noted on 8/26/15 the plan was to continue monitoring the resident ' s condition and transfer her/him to the hospital if signs and symptoms of septicemia or bacteremia became apparent. The resident was admitted to the nursing home previously on 7/31/15 for wound treatment, was noted to be non-compliant and was transferred to the hospital on [DATE] with fevers. A progress note written by the Medical Director on 8/26/15 reported an attempt to discuss the ramifications of the resident's refusal of treatment for [REDACTED]. According to the facility report of the elopement incident, on 8/27/15, the resident was driven to an appointment that was scheduled for 11:00 AM, for follow-up wound care. The resident's guardian was to meet the resident at the physician's office. When the resident had not returned to the facility at 4:30 PM the Assistant Director of Clinical Services (ADCS) phoned the physician's office and was informed Resident #2 did not appear for her/his appointment. The ADCS also contacted one of the resident's guardians who reported he/she was at the doctor's office to meet the resident but he/she did not appear. The police were notified that Resident #2 was missing.A statement from the driver dated 8/27/15 reported the driver, dropped the resident at curbside to the entrance of the medical facility and provided the resident with her/his walker.On 8/28/15 an officer from the missing persons division of the Baltimore County Police Department informed the facility that the resident took a cab to the Baltimore Washington International (BWI) Airport. On 8/29/15 the facility learned from the officer that the resident took a train to Philadelphia (from BWI), then to Phoenixville where a pastor attempted to assist him/her to St. Agnes Hospital. On 8/31/15 the officer reported to the facility that the resident changed his/her mind about going to the hospital and instead asked to be taken to BWI. A nursing progress note dated 8/31/15 at 8:45 AM reported the facility received a call from the missing persons division of the police department advising the facility that Resident #2 was no longer considered a missing person. A nursing note written on this date at 3:00 PM concluded that while the resident's decision making skills were impaired she/he, demonstrated a high level of making deliberate decisions for herself/himself. There was no documentation that indicated the resident's capacity to make decisions was reassessed by a qualified physician or reclassified by the courts at this time.On 9/2/15 the officer informed the facility that the resident was in the custody of the Harford County deputies. According to facility documents the police were informed of the resident's medical issues and advised they would accept the resident back into the nursing home. The officer stated Harford County deputies placed the resident in a cab to return to the facility but contact with the cab driver revealed the resident refused. The resident's whereabouts remained unknown at the time of the survey. In interview with the Director of Maintenance Services on 12/3/15 at 1:35 PM he/she stated the driver (Driver #1) who transported the resident to the appointment was terminated for failure to provide the appropriate level of supervision. The Director of Maintenance confirmed that the driver did not accompany the resident inside of the building, which was not consistent with the facility's protocol. However, a review of the facility's Transportation policy and procedure on 12/3/15 failed to address the issue of supervision of residents while on appointments in the community. These systems failures resulted in the elopement of this cognitively impaired and medically compromised resident thus placing him at risk for harm. Based on the findings, on 12/3/15 at 1:10 PM, an Immediate Jeopardy was identified related to the provision and care of services for Residents #2 and #3, who were identified as being at risk for elopement. The facility submitted an initial plan of removal to the Office of Health Care Quality for review at 6:50 PM on December 3, 2015. This initial plan was not accepted. The facility submitted revised plans at 7:33 PM and 7:58 PM. The final plan submitted at 7:58 PM entailed the following: elopement risk assessment being performed on Resident #3 still residing the facility, as well as all other residents in the facility; care plans updated for the other 21 residents identified at risk of elopement; elopement drills; education of staff on duty, and plan to educate all staff who were not present prior to them beginning their next shift; and elopement binders were updated. The plan was accepted and the immediate jeopardy was removed at 8:02 PM on December 3, 2015.

Based on observation, staff interviews, and review of medical records and facility investigation documents, it was determined that the facility failed to implement and maintain an effective system to address the needs of residents with exit seeking / wandering behaviors when the facility failed to correct an aging and malfunctioning elopement alarm system. This failure resulted in two residents (#1 and #3) eloping from the facility (one elopement on 4/20/15 and the other a month later on 5/20/15). Due to the on-going failure to address these known concerns that placed vulnerable residents in danger, an immediate jeopardy was called on June 23, 2015 at 12:43 PM. The facility took steps to remove the Immediate Jeopardy on June 23, at 8:31 PM while the surveyor remained onsite. The findings included: 1. Medical record review revealed that Resident #3's [DIAGNOSES REDACTED]. The resident was independent for ambulation. The admission elopement risk evaluation revealed the resident was at risk for elopement. Review of the residents physician order [REDACTED]. Check WanderGuard every shift. Change WanderGuard every three months and as needed.' Investigation of facility reported incident #MD 299 on 6/23/15 at 11:00 AM, revealed that on 4/20/15, Resident #3 was at the front desk at 9:30 AM obtaining money from (his/her) account. The resident then left the building through the front door. The receptionist noted that the door did not lock nor did an alarm sound. She immediately redirected the resident back into the building and called the nurse's station reporting that the resident had attempted to elope and that the wander guard was not functioning. Effective immediate actions to protect resident #3 were not taken. Review of the facility investigation revealed that after the reported elopement attempt, resident #3 then eloped through a back door. This was corroborated during interview with the Director of Nursing and the Maintenance Director on 6/23/15 at 11:30 AM. They reported that the resident's WanderGuard was not working and the resident left the facility thru the back door near the vending machines. At 10:15 AM on 4/20/15, two housekeepers from the facility saw a police officer speaking to the resident across the street from the facility at the convenience store and they interceded and brought the resident back to the facility. The housekeeping staff did not inform nursing staff that the resident had eloped from the facility. Housekeeping staff informed human resources staff of the elopement and then at 11:20 AM on 4/20/15, the Director of Nursing (DON) was made aware of the incident by Human Resources staff. This was more than an hour after the resident had been brought back by staff. The DON then spoke with the unit manager who also had not been notified of the resident's elopement. At 11:40 AM, the nurse obtained and placed a new WanderGuard on Resident #3. At 12:00 PM, the DON and the unit manager assessed the resident and found that the just placed WanderGuard had not been activated. During an interview with Nurse #14 on 6/23/15 at 12:00 PM, she stated the WanderGuard was working but the door was not working. Review of the resident medical record on 6/23/15 at 12:15 PM, revealed a treatment assessment record, which was signed off by the nurse on 4/20/15 (7-3) shift the WanderGuard was working, but the nurse who signed this off said she checked the WanderGuard and not the door. Testing only the WanderGuard on the resident did not effectively ensure the system was working. 2. Review of Resident #1's medical record revealed that Resident #1 was diagnosed with [REDACTED]. The admission elopement risk evaluation revealed the resident was at risk for elopement and was not capable of making (his/her) own decisions. Review of the residents physician order [REDACTED]. Change WanderGuard battery every three months and as needed. Further medical record review and investigation of complaint #MD 815 on 6/23/15 at 11:30 AM, revealed that on 5/20/15 at approximately 5:00 PM during dinner, Resident #1 started pacing around the facility and after dinner continued pacing. The resident was redirected. In interview, Nurse #9 corroborated her nursing note dated 5/20/15 which documented that at about 9:00 PM the resident was given a snack after being brought to the 2nd floor from the 1st floor having followed another resident family member. About five minutes later, the resident was noted missing from the TV room where he/she had been sitting. At 9:15 PM on 5/20/15, Resident #1 was found by staff sitting on the stairs of a house next door to the facility. Of note, 15-minute check documentation in the record indicated that at 9:00 PM and 9:15 PM Resident #1 was on the unit when other documentation revealed that he/she was actually out of the building. During interviews with the Director of Nursing and the Unit manager it was revealed the resident did have the WanderGuard in place but it did not alarm because the door part of the system was not working again. During an interview with the Administrator and Maintenance Director at 11:40 AM on 6/23/15, they reported that the WanderGuard system was not working at the time of the incident. In addition, on 6/23/15 at 12:00 PM the Regional Nurse accompanied by the surveyor and tested the wander guard system. The wander guard alarmed only when the door was pushed open, not when the door was approached by someone wearing the WanderGuard. Although the system was set to perform this way, the alarm sounding only after the door was opened would not protect residents from eloping. Interview with Nurse #9, on 6/24/15 at 10:00 AM, revealed the WanderGuard system was not working on 5/19/15 on the 7 AM - 3 PM shift, but the facility nursing staff was not made aware until 5/20/15. Nurse #9 also stated she voiced her concerns to the Administrator about the safety of the residents and staff. Documentation received from the vendor on 6/24/15 at 1:03 PM revealed the following concerns with the system: -5/19: The WanderGuard system is not locking the door when the tag gets into the field. Walked through the wiring the system for the WGD and mag locks. System is working at this time. -5/21/15- Ticket info: WG mag locks are not working. Responded: Troubleshoot with (Maintenance Director). bad fire relay. (referred) to sales for replacement.; and, -5/26/15- Ticket info: WG system not working properly in several doors. (Maintenance Director) need to schedule tech as soon as. Responded: Called and spoke with (Maintenance Director), They have issue with all WGD's ( ). Educated him on company policy with WGD and upgrading options. you're using an older version of the WanderGuard. Are you aware that this model is no longer available?. My options are limited due to the age of your equipment and we can't provide on-site support to repair or replace equipment. In an interview on 6/24/15 at 10:30 AM, staff member #13 indicated that the Maintenance Director was made aware during the morning of 5/19/15 that the WanderGuard system was malfunctioning. The main entrance doors to the facility were not closing completely and the doors were not sealing and locking. Further interview with the Maintenance Director on 6/24/15 at 12:00 PM, revealed the malfunctioning wander system was reportedly repaired on 5/23/15 but on 5/26/15 several doors were not working. A spring bolt was attached to the main door right side on 5/26/15 because at that time the door could not be locked. Due to these failings, an immediate jeopardy was called on 6/23/15 at 12:43 PM. The facility submitted an acceptable plan to remove the immediate jeopardy and it was accepted by the State Agency on 6/26/15 a 6/23/15 at 8:31 PM. The facility plan to remove the immediate jeopardy included the following: -The facility changed the locking mechanism so the interior door locks at night when the receptionist leaves and does not unlock until 8:00 AM, when the receptionist and management staff return for work. This will protect residents at risk for elopement from exiting the building at night. -The interior door, if opened by a resident wearing a WanderGuard, will alarm and facilitate the exterior door to lock automatically. Also, the facility is providing a staff member to monitor every exterior door until resolution with the WanderGuard system is determined. -The E.D (Executive Director/Administrator) is accountable for implementation and oversight of the plan to remove immediacy. -Education and in-service training provided regarding elopement policy and procedures to all Registered Nurses and Licensed Practical Nurses.