Every finding on record at Carriage Hill Bethesda

Based on record reviews and interviews, it was determined that the facility failed to resolve repeated concerns reported during Resident Council meetings. This was evident in one (#3110820 ) of seven complaints reviewed during the complaint survey.The findings include:A review of complaint #3110820 noted that The facility's telephone system is not functioning properly and requested an inspection of the system.A review of the Resident Council meeting minutes from May 1 to August 27, 2026, was completed on 8/26/26 at 9:35 AM. The review showed that on 6/9/26 and 6/16/26, concerns were raised about phones not working in some residents' rooms.A follow-up interview with Resident #111, the Resident Council President, revealed that concerns raised during the June Resident Council Meetings included Residents' phones not connecting to 911 calls. Resident #111 stated that the issue remained unresolved as of the date of this interview, 8/26/26.A subsequent interview with Resident #114, [NAME] President of the Resident Council, on 8/27/26 at 10:01 AM indicated that most residents' phones returned a busy tone when they tried to dial 911, which was concerning during an emergency. Resident #114 added that the facility was aware of the situation and demonstrated it to the surveyor by dialing 911, which did not connect and returned a busy tone.During an interview, staff #9, the Activity Director, explained that on 6/9/26 and 6/16/26, residents raised concerns about their phones; however, she was not aware of any connection issues. Staff #9 added that on 6/16/26, Resident #112 reported during the meeting that he/she did not have a phone in his/her room. She reported this to the Maintenance department but was not aware of the resolution.An interview with Resident #112 on 8/27/26 at 11:15 AM showed that he/she had requested a landline for his/her room several times from the facility but had not yet received one. In an interview with the Nursing Home Administrator (NHA), the NHA stated that staff #9 was responsible for forwarding concerns raised at the Resident Council meetings to the appropriate department for resolution. The NHA added that he was unaware of the phone connection issue and would investigate it.A follow-up interview with the NHA confirmed that some residents' phone lines could not connect to 911 calls. The NHA reported that he had called in a vendor to the facility to resolve the issue after the surveyor's intervention.

Based on record review and interview, it was determined that the facility failed to ensure resident records were accurate. This was evident for 1 (Complaint #2992977) of 7 complaints reviewed during the complaint survey.The findings include:Per the Centers for Medicare and Medicaid (CMS) State Operations Manual, Appendix PP, an Advance directive is defined as a written instruction, such as a living will or durable power of attorney (DPOA) for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated.Part 1 of the Maryland Advance Directive form indicates the selection of health care agents (DPOA).A record review on 8/26/26 at 11:05 AM revealed that Resident #109 was admitted to the facility in 2021 after an inpatient hospital stay. Additional review revealed that the resident was alert and oriented to person, place, time and situation, and was able to make their needs known and had been since their admission.On 8/26/26 at 11:32 AM a telephone interview was conducted with the complainant who said that a copy of Resident #109's power of attorney for healthcare was provided to the facility at the time of the resident's admission in 2021 and that when asked, the facility said they could not locate the document.On 8/26/26 at 11:51 AM a review of Resident #109's electronic medical records was conducted and failed to reveal any power of attorney or advance directive documents. A review of the resident's face sheet/profile page revealed the notation that the complainant was listed as the POA - Financial. Further review revealed a progress note, written by social work designee (Staff #8) that indicated on 3/20/26 the resident was provided a packet of the Maryland Advance Directives, but there was no explanation for the reason. On 8/26/26 at 1:34 PM an interview was conducted with Staff #8. When asked about Resident #109's progress note of 3/20/26 that indicated Staff #8 gave the resident the Maryland Advance Directive forms, Staff #8 confirmed that she wrote that note but could not remember why she gave the resident the forms at that time. When asked if there were any POA documents in the resident record, she looked but said she could not find any. When she was asked to review the resident's face sheet that indicated the complainant was POA - financial, she did not have an explanation for the entry in the record.On 8/27/26 at 11:05 AM an interview was conducted with the Assistant Director of Nursing (Staff #2) and she was asked about the designation of the complainant as the POA- Financial. Staff #2 said she was not sure.On 8/27/26 at approximately 1:00 PM, the Nursing Home Administrator (NHA) provided a copy of Resident #109's Maryland Advance Directive document, dated 9/28/21, and indicated the complainant was designated as the Primary Agent to make health care decisions for the resident. When asked, the NHA said that he found the document in the resident's scanned hospital records from the admission documents. The NHA confirmed that the designation in the electronic record which listed the complainant as the POA - financial, was incorrect. The NHA later provided a corrected copy of the resident's face sheet that indicated the complainant was the resident's POA for care.

Based on record review and interview, the facility failed to ensure psychotropic medication use was supported by a clear, appropriate, and documented clinical indication in accordance with professional standards of practice. This deficient practice was identified for 1 (#21) of 5 residents reviewed for unnecessary medications.Findings include: A review of the medical record for Resident #21 was conducted on 03/23/2026 at approximately 1:00 PM. The review revealed a physician's order dated 03/16/2026 for Seroquel (quetiapine) 75 mg by mouth at bedtime (administered as one 50 mg tablet and one 25 mg tablet). Seroquel is an antipsychotic medication commonly indicated for the treatment of conditions such as schizophrenia and bipolar disorder.Further review of the medical record revealed the documented indication for use as psychotic symptoms. This entry did not reflect a specific, diagnosed condition and did not constitute a clinically appropriate or sufficient indication to support the use of an antipsychotic medication.An interview was conducted on 03/23/2026 at approximately 2:13 PM with the Psychiatric Nurse Practitioner (Staff #10). During the interview, Staff #10 stated that the indication for use had been entered into the electronic medical record incorrectly.Following surveyor inquiry, the resident's record was updated to include a diagnosis intended to reflect an appropriate clinical indication for the medication.

Based on observation and interview, the facility failed to ensure residents were permitted to receive visitors at any time in accordance with resident rights, by imposing facility-wide visiting hours. This deficient practice had the potential to affect all residents residing in the facility.Findings include: On 3/23/26 at approximately 7:30 AM, during entrance into the facility, a sign was observed taped to the glass entrance door which read, Sorry for the inconvenience, visiting hours have ended Monday-Sunday (8:00 AM-8:00 PM) All holidays 9:00 AM-5:00 PM. This signage indicated the facility imposed restricted visiting hours, limiting visitation outside of the posted times.During an interview on 3/23/26 at 7:50am, the Administrator (Staff #1) stated residents are allowed visitors at any time and reported being unaware of the origin of the posted sign.During interviews on 3/23/26 at approximately 11:00 AM, multiple residents confirmed the posted visiting hours reflected the facility's current practice for visitation.During an interview on 3/23/26 at 1pm, Receptionist (Staff #41) stated she places the sign on the door each evening at 8:00 PM when she leaves the building and removes it upon her return at 8:00 AM. She further stated that the front entrance door is locked after 8:00 PM. When asked how visitors would gain entry to the building outside of the posted visiting hours, she stated there is a doorbell located on the side wall. When asked if signage was posted to inform visitors of the doorbell, she stated there was no such signage.

Based on observation and staff interview, the facility failed to: 1. Maintain proper infection control practices to prevent the potential for cross-contamination by storing soiled linen in the same room as clean linen. This was evident in 1 (first floor) of 1 linen storage areas observed during environmental rounds and has the potential to affect all residents who rely on clean linen for care and services on the first floor.2. Maintain an infection prevention and control practice to provide a safe and sanitary environment in laundry service area. This was evident by 2 of 4 laundry service areas observed during the annual survey. Findings include:1. During observation rounds conducted on 3/18/26 at approximately 9:00 AM, a room labeled bath was observed to contain three large trash cans filled with soiled linen. In the same room, two carts containing clean linen were also stored. The co-mingling of soiled and clean linen in the same area has the potential to result in cross-contamination and does not align with accepted infection prevention and control practices. During an interview on 3/18/26, Housekeeping Staff #42 acknowledged awareness of proper infection control procedures and stated that soiled linen should not be stored in the same room as clean linen. During a separate interview, Geriatric Nursing Assistant (GNA) Staff # 43 stated they were unsure how the clean linen carts were placed in the room but indicated they would remove them. This practice is not in accordance with facility policy and accepted standards of infection control, which require the separation of clean and soiled linen to prevent the spread of infection. 2. On 3/19/26 at 3:15 PM, staff personal items were observed on the folding tables in the dryer room. Follow-up observations on 03/20/26, at 10:36 AM, while rounding with Laundry Supervisor Staff #6, revealed that personal lockers in the washer area were not being utilized. Additionally, staff personal belongings, including food and drinks, were found in two areas of the laundry service. Staff #6 agreed with these concerns and committed to redirecting staff immediately. Interview, on 3/20/26 at 1:06 PM, these findings were shared with the Assistant Director of Nursing/Infection Control Staff #8 and the Administrator as a deficiency practice concern.

Based on observations and interviews with facility staff it was determined the facility failed to ensure that a resident has access to a phone and a working television (TV) remote control in their room. This was found to be evident for 1 (#109) of 62 residents reviewed during the facility's annual Medicare/Medicaid survey.Findings include:Intake # 2959654 was reviewed on 3/20/26 for multiple concerns. One of the concerns was that resident # 109 did not have a phone in the room and that the television remote control was not working.An observation was made on 3/26/26 at 10:45 AM; there was one phone jack observed on the wall between Resident #109's bed and the roommate. There were two staff that came into the room upon surveyor request for dual observation. Staff #34, a Geriatric Nurse Assistant (GNA) and staff #35 a Registered Nurse (RN). Staff #35 confirmed that there was only one phone jack in the room and the only phone line is connected to Resident #109's roommate. The nurse (#35) confirmed that Resident #109 does not have a personal phone or a facility provided phone in his/her room. The surveyor asked both staff (#34, #35) how Resident #109 is able communicate with family privately, and they both stated that sometimes, Resident #109 will use the roommate's phone. The Nurse stated that she would contact maintenance regarding the phone line for Resident #109.On the same date at approximately 11:15 AM, the Administrator asked if this surveyor would accompany him to Resident #109's room. Upon entering the resident room, the Maintenance Director (MD) staff #5 was present and pointed out that there is only one phone jack in the room. The Administrator went on to explain that there are multiple rooms in the facility that have only one phone jack. He went on to explain that before acquiring the building, the rooms were considered private. He stated that the facility is currently working on resolving this. The Administrator stated that the charge nurse carries a phone that the resident can use in the interim but confirmed that the resident does not have access to a phone.Another observation was made at that time with the Administrator and the MD, of the resident TV remote control. The MD was asked if the resident remote control worked? The MD tried multiple times to get the television to come on using the remote control and it did not turn on. The MD manually turned the TV on. The Administrator instructed the MD to change the batteries in the TV remote control. The MD verbally agreed.

Based on observation, resident interviews, and staff interviews, it was determined that the facility failed to maintain a sanitary, pest-free environment to ensure residents reside in a safe and comfortable setting. This deficient practice affected 1 out 2 floors reviewed during the annual survey. Findings include: 1. During observation rounds conducted on 3/18/26 at approximately 8:00 AM, several residents reported the presence of ants in their rooms. Residents stated that the issue had previously been reported to maintenance; however, the concern remained unresolved at the time of observation. During an interview with nursing staff, it was revealed that the facility utilizes a TELS (electronic maintenance request) system in which staff input maintenance concerns, generating a work order slip for the maintenance department. There was no evidence provided that the reported pest concerns had been addressed in a timely manner. During follow-up observation rounds on 3/19/26 at approximately 11:00 AM, this surveyor observed ants present in multiple resident rooms on the 1st floor, confirming the ongoing presence of pests. Staff #13 was notified of the findings at the time of observation and stated she would address the issue. However, the continued presence of ants over multiple days indicated the facility failed to ensure prompt and effective corrective action to maintain a pest-free environment. 2. An observation was made during rounds on 3/20/26 at 11:00AM and while talking to Resident #55 in their room, there were several ants crawling on a bag that was sitting on top of the nightstand in the resident's room. The resident stated that the ants boldly march along the window sill looking for food. The Administrator was made aware of the concern on 3/25/26 at 3:00PM.

Based on administrative record reviews and staff interviews it was determined that the facility failed to provide evidence that part-time and PRN geriatric nursing assistants (GNA) received education on abuse prevention, neglect, and exploitation training annually. This was evident for 7 (#17, # 21, #22, #24, #30, #39, #40) of 8 GNA employee and education files reviewed during the annual survey. The findings included:On 03/25/2026 at 02:09 PM the surveyor interviewed the assistant director of nursing (ADON) and staff educator, staff #8 regarding the annual clinical training requirements of the geriatric nursing assistants (GNAs). The ADON stated that she works closely with the HR director regarding ensuring that employees are up to date with their competency training annually. The surveyor inquired whether the annual training provided was different for PRN, agency, and Full time GNA staff. The ADON responded yes. The human resources director, staff #9 also stated that part-time and PRN GNAs are not required to demonstrate compliance with annual clinical training by facility.The surveyor asked the ADON whether the requirements for compliance with the 12-hour annual clinical competency training were different for the PRN, part-time, and/or full time GNAs and the ADON responded, yes. ADON stated that the part-time and PRN GNA staff are not required to meet the annual clinical competency and /or annual Relias online training requirements. The ADON further stated that she and the HR Director use a spreadsheet to track the due dates for the competency training of the GNA staff. The ADON stated the annual hands-on clinical competency training is usually offered during the months of January through March. The 2026 competencies have not been offered yet.On 03/26/2026 at 11:30 AM the review of the human resource files and the list of PRN and part-time GNA staff revealed the facility' failure by the DON and the administrator to ensure that annual abuse, neglect, and exploitation clinical training was completed.On 03/26/2026 at 12:26 PM the surveyor discussed the findings related to deficit practice related to the facility's lack of evidence related to the required compliance with the provision of annual abuse, neglect, and exploitation training for part-time and PRN GNA staff.

Based on review of employee human resource records, education training records, spreadsheets, and interviews it was determined that the facility failed to have a system in place to ensure that PRN and part-time geriatric nursing assistants (GNAs) received at least 12 hours of clinical in-service training annually. This was found to be evident for 7 (#17, # 21, #22, #24, #30, #39, #40) of 8 part time or PRN GNAs employee files and educational files reviewed during the annual survey.Findings include:On 03/25/2026 at 02:09 PM the surveyor interviewed the assistant director of nursing ADON and staff educator, staff #8 regarding the annual clinical training requirements of the geriatric nursing assistants (GNAs). The ADON stated that she works closely with the HR director, staff #9 in regard to ensuring that GNA employees are up to date with their annual clinical competency training. The surveyor asked the ADON whether the annual training provided was different for PRN, agency, and Full time GNA staff. The ADON responded no.The surveyor asked whether the requirements for compliance with the 12-hour annual clinical competency training were different for the PRN, part-time, and/or full time GNAs and the ADON responded, yes. ADON stated that the part-time and PRN GNA staff are not required to meet the annual clinical competency and /or annual Relias online clinical training requirements. ADON further stated that she and the HR Director use a spreadsheet to track the due dates for the competency training of the full-time GNA staff.On 03/26/2026 at 08:30 AM the surveyor requested the HR files of nine PRN and part-time GNA employees. Based on the list of PRN and part-time employee list provided by the facility, seven out of eight part-time or PRN GNA staff did not have evidence of the regulatory/mandatory 12- hour annual clinical training required for geriatric nursing assistants.On 03/26/2026 at 12:11 PM the administrator brought the three policies requested: abuse, neglect, exploitation, with last review date of 09/02/2024, HR-024, Orientation, and Continuing Education. The facility did not provide a policy which included the exemption of PRN and part time GNA staff from mandatory annual clinical in-service training.On 03/26/20226 at 12:26 PM the surveyor spoke with the DON and the ADON regarding the facility's inability to demonstrate that all PRN and Part-time GNA staff are being held to the same standard of completing 12 hours of clinical education each year as the full time GNA staff. The DON and the ADON agreed that currently they are not requiring the PT and PRN GNA staff to acquire the same annual mandatory clinical education hours of training as the full-time staff. The facility administrator was made aware of the deficient practice as well.

Based on observation, medical record review, and staff interview, the facility failed to ensure that a resident received the planned breakfast meal and/or was provided an alternative meal or nutritional supplement after the original meal was not consumed. This deficient practice had the potential to result in inadequate nutritional intake for 1 (Resident #21) of 1 residents reviewed for nutritional status.Findings include: On 03/18/2026 at approximately 9:00 AM, during a breakfast meal observation, Resident #21 was observed propelling herself/himself in a wheelchair in the hallway. At that time, the resident's meal tray was observed on the bedside table inside the resident's room. The resident's plate was noted to be on the floor with oatmeal and eggs spilled. The amount of food observed on the floor indicated the meal had not been consumed.Review of the medical record revealed Resident #21 was cognitively impaired and had experienced recent weight loss, placing the resident at increased risk for inadequate nutritional intake.At the time of the observation, the Director of Nursing (DON) was present in the hallway and was made aware of the situation. The DON notified housekeeping staff to address the spilled food; however, there was no evidence the resident was assessed for meal consumption or offered a replacement meal, substitute tray, or nutritional supplement.During an interview on 03/18/2026 at 11:00 AM, the Certified Dietary Manager stated that no additional breakfast tray had been requested for Resident #21.During an interview on 03/18/2026 at 11:30 AM, Staff Nurse #15 stated she was not aware that the resident required a replacement meal.There was no documented evidence that the facility ensured the resident received adequate nutrition after the observed meal was not consumed.

Based on medical record review and interview, the facility and facility pharmacy services failed to identify incorrect indications/reasons for medications being administered. This was evident for 1 (#50) of 8 residents reviewed for medications during the annual survey. The findings include: During review of Resident #50's March 2026 Medication Administration Record (MAR) on 03/19/2026 at 10:30 AM revealed that on 03/09/2026 the physician ordered Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) Give 1 tablet by mouth two times a day for seizures and on 03/26/2025 the physician ordered Lamotrigine Oral Tablet 25 MG Give 4 tablet by mouth one time a day for epilepsy. Further review of Resident #50's medical records revealed that resident has no history or current medical condition / diagnosis of seizures or epilepsy. During an interview on 03/19/2026 at 12:30 PM staff #2 stated, (The resident) Does not have epilepsy or seizures and there is nothing in the medical file that states he/she ever had a history of epilepsy or seizures. Staff #2 also stated, I will let the doctor know so this can be corrected. Staff #2 was unable to explain how the facility or pharmacy verified that the correct indication/reason was used for Resident #50's medication orders.

Based on interview and record review, the facility failed to ensure that a resident's right to make his/her own decisions, including the right to participate in and direct his/her personal and financial affairs, and the right to refuse services, was honored. The facility also failed to obtain the resident's consent prior to submitting a Medicaid application and inaccurately represented the resident's decision-making capacity. This deficient practice was identified for 1 of 1 resident (Resident #69) reviewed for resident rights.Findings include: During an interview conducted on 3/24/25 at approximately 11:00 AM with Resident #69 and the resident's daughter regarding complaint #2719381, Resident #69 stated that he/she had previously informed the social worker that he/she did not want to apply for Medicaid and planned to return home. The resident and the resident's daughter further stated that the facility submitted a Medicaid application without the resident's knowledge or consent. Resident #69 stated, I don't know how they could do that without my information and my permission.During an interview with the Administrator (Staff #1) on 3/24/25 at approximately 1:00 PM, the Administrator confirmed that a Medicaid application had been submitted on behalf of the resident, stating it was done to help him/her.During an interview with the Business Office Manager (Staff #13) on 3/25/25 at approximately 1:30 PM, she stated she had been advised by the facility that it was acceptable to submit the Medicaid application on the resident's behalf.Upon request, the surveyor reviewed the Medicaid application submitted for Resident #69. Review revealed the application was completed under the designation applicant without representative who lacks capacity to appoint a representative. However, review of the resident's medical record revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact and capable of making his/her own decisions.These findings demonstrate the facility failed to honor the resident's right to make informed decisions and to refuse services and failed to accurately represent the resident's decision-making capacity.

Based on observation, interview and record reviews, it was determined that facility staff failed to:1. Honor residents' rights to file grievances anonymously, and failed to provide blank Grievance forms in prominent locations throughout the facility. This was evident for 4 (#4, #25, #74, #83) out of 6 residents from 3/23/26 Resident Counsel meeting.2. Ensure that residents were provided with prompt follow-up responses to their grievances. This was found to be evident for 1 (Resident # 55) of 2 residents reviewed for care concerns during the facility's annual Medicare/Medicaid survey.Findings include:1. During a facility tour on 3/19/26 at 9:40 AM, it was observed that the facility did not post blank grievance forms to be made available in prominent areas. In an interview on 03/20/26 at 9:35 AM, the Administrator stated that a 24/7 care concern line is available for residents to report grievances via a voicemail system. However, the facility's corporation handled the care concern line concerns; the Administrator could not know for sure how concerns were circled back to the facility staff. He further stated that blank grievance forms are at the front lobby counter and at the nursing stations' counters. Once completed, residents may submit grievance forms to the Administrator, the Director of Nursing, or Social Work Staff #4 and #16. After submitting the forms, the appropriate department heads processed the investigations. While the standard turnaround time for resolutions is five business days, the Administrator held and expedited cases involving concerns of abuse, neglect, or injury. Additional observations were made from 03/20/26, at 10:15 AM, Signage: Both Social Workers' offices lack identification. In contrast, other staff offices, such as those for the Activity Coordinator and Business, are properly identified. No grievance forms were available at the lobby front desk counter nor the Nurse-stations' counters. Staff members had to retrieve the blank forms from the back areas upon request. A record review conducted on 03/20/26 at 10:33 AM, regarding the facility's Grievance/ Residents Monthly Counseling binder, revealed that a paper system was used prior to October 2025. It was noted that Social Worker staff initiated all grievance forms, rather than residents initiating them directly or through anonymous submissions. Additionally, there was no record of Grievance resolution statements provided back to the residents. In a subsequent interview, the Administrator confirmed that blank grievance forms were inaccessible to residents at this time. During a Resident Council meeting on 03/23/2026 at 11:38 AM, most residents reported they were unaware of the grievance process or where to access the grievance blank forms. 2. During the initial screening of residents on 3/18/26 at approximately 8:30 AM, residents on the 100-unit hallway reported to members of the state survey team that they fear reprisal of making complaints regarding care concerns. This information was discussed with the administration team on the same date at approximately 12:00PM and the administrator stated that they would investigate. On 3/20/26 at approximately 9:00AM the Administrator reported to the survey team that they were continuing audits with residents in reference to the concern reported by the survey team and provided updates. During follow-up interviews with residents on the 100-hallway following the audit, resident # 55 was asked if s/he was asked about any concerns. At this time the resident told the surveyor that approximately 2 weeks ago, s/he reported during a resident council meeting that a staff member was rough while transporting him/her in a wheelchair. The resident stated that the Administrator was present during the council meeting. The resident stated that s/he also told the Administrator about this incident once again on the previous evening of 3/19/26, when he came in to speak to the resident roommate about a concern. On 3/20/26 the resident council president gave authorization for the survey team to review resident council minutes. Upon review, a resident council minutes form dated 3/10/26, on the bottom of page 3, indicated that there were no concerns for Administrator. During an interview on 3/20/26 at 12:15 PM with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the NHA was asked about resident #55 reporting during a resident council meeting earlier this month, a concern regarding a staff being rough while transporting him/her in a wheelchair. The Administrator stated that on 3/10/26, he attended a resident council meeting, and the resident did report a concern. He further stated that resident # 55 reported that staff need to be more careful during transfer. He was asked was a follow-up was done regarding the concerns the resident presented at the council meeting and he stated, no. At this time the surveyor asked the Administrator if he spoke to resident # 55 on yesterday evening (3/19/26) about the same concern that was mentioned at the resident council meeting and he confirmed, yes. He stated that when he spoke to the roommate yesterday (3/19/26) resident # 55 asked about his/her concerns that s/he spoke about at the council meeting, and that is when he remembered that he did not follow-up. The Administrator explained that when grievance is filed, the administration team follows up on all concerns, and he acknowledged that he had forgotten. He stated that he would immediately address the residents' concerns.

Based on medical record review and staff interview, the facility failed to ensure the consultant pharmacist identified and reported an irregularity related to an inaccurate and incomplete medication order. This deficient practice was identified for 1 (#21) of 5 residents reviewed for pharmacy services.Findings include: A review of the medical record for Resident #21 was conducted on 03/23/2026 at approximately 1:00 PM. The review revealed a physician's order dated 03/16/2026 for Seroquel (quetiapine) 75 mg by mouth at bedtime, to be administered as one 50 mg tablet and one 25 mg tablet.Further review revealed the documented indication for use as psychotic symptoms. This entry was nonspecific, did not reflect a diagnosed clinical condition, and did not constitute an appropriate or sufficient indication for the use of an antipsychotic medication, representing an irregularity in the medication order.On 03/23/2026 at approximately 2:13 PM, the Psychiatric Nurse Practitioner (Staff #10) stated during interview that the indication had been entered incorrectly in the electronic medical record. Following surveyor inquiry, the resident's record was updated to include a diagnosis intended to support the medication's use.There was no evidence that the consultant pharmacist identified, documented, or reported this irregularity, specifically the lack of an accurate and clinically appropriate indication for an antipsychotic medication, during the medication regimen review on 3/13/26.This deficient practice demonstrates a failure of pharmacy services to ensure the identification and reporting of medication regimen irregularities in accordance with regulatory requirements.

Based on record review and staff interview, it was determined that the facility failed to ensure a resident was free from unnecessary medication. This was evident for 1 (#132) of 5 residents reviewed for unnecessary medications during the annual survey. The findings include:A review of Resident #132's medical record on 03/26/2026 at 12:45 PM revealed that on 12/18/2025 the physician ordered Colace Oral Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth two times a day for constipation and on 12/22/2025 the physician ordered Colace Oral Capsule 100MG (Docusate Sodium) Give 1 capsule by mouth every 12 hours for Constipation. Review of January 2026 Medication Administration Record (MAR) revealed that Resident #132 received Colace on:01/01 once on day shift twice on evening shift01/03 twice on day shift and twice on evening shift01/04 twice on day shift01/05 once on day shift and twice on evening shift 01/06 twice on evening shift 01/07 twice on day shift and twice on evening shift 01/08 twice on day shift During an interview on 03/26/2026 at 1:00 PM with staff #2, Resident #132's Medication Administration Records were reviewed with surveyor and staff #2 agreed that the Colace orders were duplicated and administered in error.

Based on resident medical record review and interview, it was determined that the facility failed to ensure that medications were administered as ordered. This was evident for 1 (#50) of 1 resident reviewed for significant medication errors during the annual survey. The findings include:1.During review of Resident #50's medical record on 03/23/2026 at 9:10 AM revealed that on 10/06/2025 the physician ordered Acetaminophen Oral Tablet 500 MG (Acetaminophen) give 2 tablet by mouth every 8 hours as needed for moderate pain do not give more than 3g within 24 hours. On 02/19/2026 the physician ordered Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) give 2 tablet by mouth three times a day for pain. Review of March 2026 Medication Administration Record revealed Resident #50 received the 3 times a day Acetaminophen and received as needed Acetaminophen totaling 4000 mg which exceeds 3g (3000 mg) on 03/05 and 03/17. During an interview on 03/23/2026 at 10:00 AM with staff #2, Resident #50's March 2026 Medication Administration Records were reviewed with surveyor. Staff #2 agreed that Resident #50 received over 3g of Acetaminophen on 03/05, 03/17 and would contact the doctor to have medication order corrected. 2.Review of Resident #50's medical record on 03/23/2026 at 9:20 AM revealed that on 09/11/2025 the physician ordered Oxycodone HCL Oral Tablet 5 MG (Oxycodone HCL) Give 1 tablet by mouth every 6 hours as needed for mild to moderate pain, and Oxycodone HCL Oral Tablet 7.5 MG (Oxycodone HCL) Give 7.5 mg by mouth every 6 hours as needed for severe pain rated 7 to 10. Review of March 2026 Medication Administration Records revealed on 03/18/26 Resident #50 received Oxycodone 5mg 1 tablet by mouth at 07:47 AM for pain level 5, and Oxycodone 7.5mg 1 tab by mouth at 09:37 AM for pain level 4.During an interview on 03/23/2026 at 10:05 AM with staff #2, Resident #50's March 2026 Medication Administration Records were reviewed with surveyor. Staff #2 agreed and verified that resident #50 was given an additional dose of Oxycodone 7.5 mg in error because it was before the 6-hour time frame. 3.Review of Resident #50's medical record on 03/23/2026 at 9:25 AM revealed that on 09/11/2025 the physician ordered Oxycodone HCL Oral Tablet 7.5 MG (Oxycodone HCL) Give 7.5 mg by mouth every 6 hours as needed for severe pain rated 7 to 10. Review of March 2026 Medication Administration Records revealed Resident #50 received Oxycodone 7.5mg 1 tab by mouth on 03/01, 03/02, 03/10, 03/15, 03/18 for a pain level of 4, on 03/14 for a pain level of 6 and on 03/18 for a pain level of 3.During an interview on 03/23/2026 at 10:15 AM with staff #2, Resident #50's March 2026 Medication Administration Records were reviewed with surveyor. Staff #2 agreed and verified that resident #50 was given Oxycodone HCL Oral Tablet 7.5 MG for resident pain levels that were not severe rated 7 to 10 per physician orders and was given in error.

Based on observations and interviews with residents and facility staff it was determined the facility failed to ensure that residents' call lights used to notify staff that assistance is needed were within reach. This was found to be evident for 3 (#60, #107, # 67) of 105 residents observed during the initial tour conducted during the facility's annual Medicare/Medicaid survey.Findings include:Screening and observation rounds were conducted on the second unit hallway on 3/18/26 at 8:15 AM and the following concerns were identified:Resident # 60 was observed in the resident's room, and the resident call light was observed on the floor at 8:20AM. The nurse (staff # 12) was notified at this time and came into the room and picked up the call light off the floor.Resident #107 and #67 were observed in their room. Resident #67s call light was on the floor and resident #107's call light was hanging from the top of the bed onto the floor, out of reach of the resident.Both residents #107 and #67 complained of pain. The nurse (staff # 12) who came into the room to retrieve the call bells and placed them within the residents' reach attended to the resident's needs.The DON was made aware of the surveyor findings on 3/18/27 at 11:30 AM

Based on observation and staff interview, it was determined the facility failed to procure, store, prepare, distribute, and serve food under sanitary conditions and in accordance with professional standards for food safety, thereby placing residents at risk for foodborne illness and contamination. This deficient practice was identified during the annual survey and had the potential to affect all residents receiving meals prepared by the dietary department.Findings include:On 3/18/26 at 9:00 AM, an initial tour of the facility kitchen was conducted in the presence of the Certified Dietary Manager. Observation of the dietary department revealed multiple breaches in sanitary food handling, storage, and environmental cleanliness, including:-Seven pre-poured syrup containers were observed stored on a visibly soiled utility table and were not labeled or dated, preventing identification and safe use.-A large plastic container of salad dressing was observed open and unlabeled in the walk-in refrigerator, failing to ensure proper food identification and protection from contamination.-Opened bread products were observed without labeling or dating, failing to ensure product integrity and safe consumption.-Multiple items in the dry storage room were observed unlabeled, indicating a systemic failure to follow safe food storage practices.-Food debris and a liquid substance were observed on the kitchen floor near the walk-in freezer, creating a risk for contamination and unsanitary conditions.-The walk-in freezer had a buildup of ice beneath storage racks where food was maintained, indicating failure to maintain equipment in a sanitary condition and increasing risk for contamination.-A red substance was observed spilled across metal shelving in the walk-in refrigerator, demonstrating failure to maintain clean and sanitary food contact and storage surfaces.-The three-compartment sink contained large pots; however, review of the 3 Compartment Sink Log (Chemical Sanitation) log revealed the last documented entry was dated 3/17/26.During an interview on 3/18/26 at 9:30 AM, the Certified Dietary Manager acknowledged the findings and confirmed the identified practices were not in accordance with facility policy or accepted food safety standards.A follow-up observation conducted on 3/23/26 at 10:44 AM revealed the previously identified concerns had been corrected; however, the deficient practices existed at the time of observation and constituted noncompliance.

Based on interviews and record review, it was determined the facility staff failed to ensure alleged abuse/neglect is reported initially no later than 2 hours to the regulator agency Office of Health Care Quality (OHCQ) after the facility's staff was made aware. This was found evident in 1 (Resident #117) out of 16 residents reviewed for abuse/neglect during an annual survey. The findings include: An interview conducted on 03/25/26, at 10:55 AM with the Administrator regarding a Facility Reported Incident #2807275 involving Resident #117. According to the Administrator, Resident #117 was allegedly hit on the back by Wound Nurse Staff #38 on 03/17/26. The Administrator stated that facility staff became aware of the incident at approximately 1:00 PM that day. The matter was subsequently reported to the Office of Health Care Quality (OHCQ) on 03/17/26, at 3:16 PM.A review of the facility's Facility Report Incident file on 3/25/26 at 1:12 PM revealed several concerns regarding this incident involving Resident #117. According to the Administrator's interview statement of 3/17/26, the resident voiced pain and discomfort, noting that Staff #38 did not respond when asked why they hit the resident on the back. Furthermore, an interview with the resident's family confirmed they were present during the incident and heard the resident ask the staff, Why did you hit me? Based on these statements, Staff #38 failed to report the incident immediately, ignored this resident's direct verbal concern, and walked out of the resident's room. This was noted alongside wound documentation date and time 3/17/26 at 11:44 AM. Regarding the final interview conducted on 03/26/26, at 12:55 PM with the Administrator. Based on interview statements from Resident #117 and their family, the resident asked, Why did you hit me? This occurred following a wound assessment on 03/17/26, at 11:44 AM. Staff #38 failed to immediately report this direct verbal concern, resulting in a reporting delay. Although the Administrator claimed the facility only became aware of the incident around 1:00 PM, the initial concern was raised significantly earlier. The initial report was not submitted to the Office of Health Care Quality (OHCQ) until 3:16 PM. The Administrator was made aware that this delay exceeds the required two-hour notification window for reporting such incidents to the regulatory agency, constituting a practice deficiency.

Based on record review and interview, it was determined that the facility failed to complete and transmit the Minimum Data Set (MDS) assessments. This was evident for 27 (Residents #4, #6, #9, #11, #22, #23, #30, #32 #46, #62, #64, #65, #71, #72, #76, #78, #81, #87, #91, #93, #94, #95, #96, #99, #101, #102 and #109) of 33 residents reviewed for resident assessments during the annual survey. The findings include: Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The data elements (also referred to as items) in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and between nursing homes and outside agencies. MDS assessments need to be accurate to ensure each resident receives the care they need. Nursing homes are required to submit the Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source to Centers for Medicare and Medicaid Services (CMS') Internet Quality Improvement and Evaluation System (iQIES). Skilled nursing facilities (SNFs) are required to transmit additional MDS assessments for all Medicare beneficiaries in a Part A stay reimbursable under the SNF Prospective Payment System (PPS). Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. On 1/9/25 at 3:00 PM, a review of the MDS assessments revealed that the following MDS assessments were not completed and not transmitted in a timely manner: 1. Resident #4- ARD 11/25/2024 Annual 2. Resident #6- ARD 11/04/2024 Annual 3. Resident #9- ARD 11/30/2024 Quarterly 4. Resident #11- ARD 12/05/2024 Quarterly; 11/30/2024 Annual 5. Resident #22- ARD 10/27/2024 Quarterly 6. Resident #23- ARD 11/26/2024 Discharge Return Not Anticipated 7. Resident #30- ARD 11/15/2024 Quarterly 8. Resident #32- ARD 10/23/2024 Quarterly 9. Resident #46- ARD 11/18/2024 Quarterly 10. Resident #62- ARD 11/12/2024 Quarterly 11. Resident #64- ARD 10/27/2024 Quarterly 12. Resident #65- ARD 11/28/2024 Quarterly 13. Resident #71- ARD 11/08/2024 Annual 14. Resident #72- ARD 10/21/2024 Discharge Return Anticipated 15. Resident #76- ARD 11/06/2024 Quarterly 16. Resident #78- ARD 10/23/2024 Quarterly 17. Resident #81- ARD 11/30/2024 Quarterly 18. Resident #87- ARD 10/23/2024 Quarterly 19. Resident #91- ARD 11/01/2024 Discharge Return Not Anticipated 20. Resident #93- ARD 11/26/2024 Discharge Return Not Anticipated 21. Resident #94- ARD 11/24/23 Annual 22. Resident #95- ARD 11/8/2024 Discharge Return Not Anticipated 23. Resident #96- ARD 11/07/2024 Quarterly 24. Resident #99- ARD 11/14/2024 Quarterly 25. Resident #101- ARD 11/24/2024 Quarterly 26. Resident #102- ARD 12/04/2024 Quarterly 27. Resident #109- ARD 11/23/2024 Quarterly; 11/26/2024 End of PPS Part A Stay On 1/10/25 at 10:19 AM, during an interview with the Lead MDS Coordinator, she stated that the timeline for completing MDS assessment was within 14 days of the ARD. She revealed that the facility was aware of the late assessments, and added that lately, they were not able to complete the assessments due to the increased number of facility admissions and the number of nurses who completed the MDS assessments were trimmed down from 3 to 2. She added that they prioritize the Medicare assessments and then the Medicaid and Private ones. She stated that currently, it was just her and the Licensed Practical Nurse (LPN #14), who did the MDS assessments. On 1/10/25 at 11: 08 AM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were notified of the concern.

Based on observations, record review, and family and staff interviews, it was determined that the facility failed to have a system in place to: 1.) identify and address residents at risk for elopement to provide the appropriate interventions to keep them safe, 2.) ensure doors that opened into stairwells and that exited out of the building were appropriately used and monitored to keep residents safe, and 3.) prevent systematic disarming of alarm systems allowing cognitively impaired residents access to exit doors. These deficient practices resulted in 2 residents (Resident #9 and Resident #10) leaving the facility unsupervised and undetected and had the potential to affect all vulnerable residents that require interventions for increased supervision and monitoring for safety. As a result of these failures, an immediate jeopardy was called on [DATE] at 7:00 PM and the immediate jeopardy template was provided to the facility. 1. A review of complaint MD 570 on [DATE] revealed an allegation that a resident had eloped from the facility in early [DATE]. The complaint also alleged that the nursing staff was not aware of the resident's elopement until the resident was brought back to the facility by local police and the resident ' s responsible party. A review of the facility Elopement and Wandering policy on [DATE] revealed no implementation date, no date of the last review, or a signature of the person who last reviewed and approved the policy. The policy stated that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Under the Policy Explanation and Compliance Guidelines: 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering, indicated the following will happen: a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team, b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan, c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff, d. Adequate supervision will be provided to help prevent accidents or elopements, e. charge nurses and unit managers will monitor the implementation of interventions, the resident ' s response to interventions, and document accordingly, f. the effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. A review of Resident #9's closed medical record on [DATE] revealed that Resident #9 was admitted from another Long Term Care facility on [DATE] with diagnoses that included: Dementia and [CONDITION(S)]. The nursing staff assessed Resident #9 for wandering on [DATE] and indicated Resident #9 was at risk for wandering. Reviews of Resident #9's baseline care plans revealed that the nursing staff had not initiated any type of wandering or elopement prevention care plan after admission. Further review revealed that on [DATE] Resident #9's Brief Interview For Mental Status (BIMS) indicated that Resident #9 was Severely Impaired cognitively. A review of Resident #9's [DATE] progress notes revealed a nursing progress note dated [DATE] at 8:51 PM that indicated during the 7 PM medication pass, the nurse was greeted by Resident #9 and Resident #9's family member. Resident #9's family member informed the nurse that s/he was contacted by the local police because Resident #9 was found outside and away from the facility. When asked, Resident #9 stated that s/he just walked out of the facility. In an interview with a former Director of Nurses (DON) on [DATE] at 1:46 PM, the former DON stated that during the investigation into Resident #9's [DATE] elopement, it was identified that Resident #9 was able to just walk out of the building. The former DON stated that on Sunday, [DATE], there were many family members onsite. No one recognized Resident #9 as a current Resident and Resident #9 was not wearing an anti-elopement bracelet at the time. The former DON stated that Resident #9 went through a door on the first floor down the hall from the nurse's station. A review of the facility investigation revealed Resident #9 was last seen around 7 PM on [DATE] and then was brought back to the facility by police escort and Resident #9's responsible party at 7:30 PM. In an interview with the facility Maintenance Director #9 on [DATE] at 11:39 AM, the maintenance director stated that s/he did not recall the elopement on Sunday [DATE] because s/he was off that day. The maintenance director stated that the facility has a wander guard system to help prevent elopements and that the system is checked weekly but there was no documentation to demonstrate the staff were performing the weekly tests. An interview with the [DATE] evening shift charge nurse was conducted on [DATE] at 1:17 PM. The [DATE] charge nurse stated that on Sunday, [DATE], it was his/her first time working with Resident #9, and s/he was not sure if Resident #9 had a wander guard bracelet on. The [DATE] evening shift charge nurse stated that there had been a resident death on the unit that day and many people were going in and out of the facility. The [DATE] evening shift charge nurse stated that after Resident #9's elopement, s/he did not review any of the facility security cameras and that s/he was not asked to review the facility security cameras. The [DATE] evening shift charge nurse stated that it was thought that Resident #9 had eloped thru the facility front door on the first floor at the time of the elopement, but the facility did not conduct a thorough investigation and review camera footage to determine how Resident #9 eloped. In an interview with Resident #9 ' s responsible party (RP) on [DATE] at 3:40 PM, Resident #9 ' s RP stated that s/he was first made aware of Resident #9 ' s elopement on [DATE] by the local police. The police officer indicated to Resident #9 's RP that Resident #9 was found approximately 1 mile away by a citizen who notified the police. The police officer also informed Resident #9 ' s RP that Resident #9 had crossed over a 6-lane automobile intersection before being assisted by a citizen. The police officer assisted Resident #9 ' s RP in returning Resident #9 back to the facility at approximately 7:30 PM. 2. An interview regarding complaint MD 570 was conducted with Staff #3 on [DATE] at 09:20 AM. Staff # 3 stated that there had been no residents identified as at risk for wandering or elopement in the past 90 days. However, at 11:24 AM, s/he returned to the conference room to inform the survey team, that Resident #10, who was no longer in the facility, had a Wanderguard device, and eloped from the facility on [DATE]. Staff #3 submitted an electronic document titled Elopement to surveyors at 11:29 AM. The Director of Nursing (DON) entered the conference room at 11:31 AM and was interviewed. The DON stated that on [DATE] she was informed that the resident had left the building. When asked if she reported the elopement to the state agency, the DON replied it was not considered an elopement because the resident did not leave the property. A review of Resident #10 ' s medical records conducted on [DATE] at 09:45 AM showed that Resident #10 was admitted on [DATE] with diagnoses to include dementia and debility weakness. According to admission documentation, the resident's spouse indicated a history of multiple falls. An Admission Wandering Risk Assessment conducted on [DATE] indicated the resident scored a 9, indicating at risk, however, there were no documented interventions implemented to address the wandering risk. The resident's Brief Interview for Mental Status (BIMS) assessment on [DATE] resulted in a score of 12, which indicated that the resident ' s cognition was moderately impaired. However, a review of the [DATE] Five-Day admission assessment under section P: revealed a Wander/Elopement alarm was not used on the resident. Electronic nursing notes dated [DATE], and [DATE] indicated that the resident was wandering on the unit with the need for redirection. However, there was no documentation to support that the facility staff alerted the department managers, the resident ' s physician, conducted Wandering Risk Assessments, or provided additional safety interventions for the resident. Review of Resident 10 ' s care plan revealed a care plan for elopement risk/wanderer risk related to impaired safety awareness for wander outside/basement however this care plan was not initiated until after the resident eloped on [DATE]. Interview with Staff #15 on [DATE] at 12:18 PM revealed that the resident had a history of wandering on the unit. Staff #15 stated that several days before the elopement Resident #10 ' s spouse was no longer able to visit. Every day after the resident would often wander throughout the day and wandered out of their room in search of their spouse. Staff #15 added that the resident was always fully dressed and well-groomed and could easily be mistaken for a visitor. An interview with Staff #14 in the presence of the DON conducted on [DATE] 4:42 PM revealed that on [DATE] while returning from a break, Staff #14 spotted the resident in the parking lot. Staff #14 added that until the resident spoke, they thought s/he was a visitor. Review of an order dated [DATE] indicated to place a Wander/Elopement bracelet on Resident #10 ' s right ankle and to check for placement every shift and as needed. During an interview with the DON on [DATE] at 11:50 AM, she said on [DATE] she assessed the resident, initiated the order and placed the wander guard band on the resident that same day. However, review of the [DATE] Treatment Administration Record failed to show that the Wanderguard was placed on [DATE]. Further review showed that nursing documentation of the presence of the band and the start date of the order were for [DATE]. During an interview with Maintenance Director #9 on [DATE] at 12:18 PM, he stated that the Wander/elopement devices are always available for staff to place on residents who need them. Maintenance Director #9 stated that there are wanderer detection indicators located at all the exterior leading doors in the facility. The door alerts are activated whenever anyone wearing a wander guard bracelet comes near the exit doors. The detection system has been in place for over 7 years, and they are tested for proper operation weekly, However, Staff #9 had not recorded the weekly test results until June of 2022. Maintenance Director #9 denied any knowledge of Resident #10 leaving out of the building through the basement ' s exterior leading exit door on [DATE] as staff reported. Staff #9 agreed to take the surveyor to the basement to demonstrate the wanderguard alarm system. An observation of the employees ' basement exit hallway was conducted on [DATE] at 12:20 PM. The interior left side door frame of the exit door had a wanderguard detector alarm device. Maintenance Director #9 pushed the keypad on the detector device then held a wanderguard bracelet near the left door. A loud alarm sounded from the device and a voice was overheard repeatedly stating all staff to check the employees ' exit door. The alarm continued until Maintenance Director #9 entered the numeric password in the keypad. Although the alarm had stopped, the receptionist continued with the announcement and several staff members had arrived at the area. Surveyor conducted observations of all the facility ' s stairwell and exterior leading exit doors on [DATE] at 12:45 PM. Observation of the residents ' second floor unit was conducted at 12:48 pm. While standing at the nursing station, an unidentified individual was seen heading down the right corridor and proceeded through a stairwell exit door at the end of the hallway, however, there were no alarms heard. Surveyor walked to the stairwell door and noted there was no wanderguard detection device seen. Surveyor opened the door and one low 2-note chime alarm was heard. Surveyor kept the door open for 15 seconds, however there was no further sound heard. The surveyor proceeded down the two flights of steps and opened the stairwell door at the facility ' s ground level. No sound was heard when the door was opened, in addition, no wanderguard alarm system device was present. Surveyor stood in the stairwell, and kept the door open for 15 seconds, however there was no additional sound heard. Surveyor stepped out of the doorway and observed staff in the hallway on the ground floor however, no one approached the stairwell door. Surveyor walked across the ground level hallway onto the opposite stairwell door. There was no wanderguard alarm system device observed on the stairwell door. When the door opened no sound was heard. The door was kept open for 15 seconds with no sound heard. Surveyor went down the 2 flights of stairs to the basement level stairwell door. No wanderguard alarm system device was observed on the basement stairwell door. In addition no sound was heard when the door was opened. An observation of all the facility stairwell doors and exits were conducted on [DATE] at 11:16 am in the presence of Maintenance Director #9. Observation of the second floor residents ' unit revealed a T-shaped hallway. Observation of the unit began at the middle hallway, near the living/room dining elevator area. Surveyor and Maintenance Director #9, proceeded up the hallway past the nurses ' station and headed toward the door located at the end of the right wing of the T-shaped hallway and asked Maintenance Director #9 to open the door. S/he opened it, and one low 2-note chime was heard. Surveyor asked if there were staff at the nursing station would they hear the chime? Staff #9 pointed down the hallway towards the nursing station and stated there was a light on the ceiling that could be seen to notify staff that 2the door was opened. S/he added that there was a 2nd light next to it which would light the same for the stairwell door on the opposite side of the unit. Surveyor asked her/him to reopen the door. When the door opened the single 2-tone chime was heard and a light was lit on the ceiling where s/he indicated. However, when the 2-tone chime stopped the light went off. This was done several times in 1.5 minutes. Each time, staff were visible in the hallway, however no one responded to the chime or to the light on the ceiling. On [DATE] at 11:20 AM, Surveyor noted Staff #16 standing in the hallway nearby at resident Room #222. When asked, s/he said they did not hear the stairwell door chime and was unaware of the presence or purpose of the light on the ceiling at the nurses ' station. Surveyor conducted the same observation at the left end of the second floor unit with the same results, the 2-tone chime rang once, the light at the ceiling lit until the 2-tone chime stopped and no staff responded to the door chime or indicator light. Surveyor and Staff #9 proceeded down the two flights of stairs to the ground level. An observation of the stairwell doors was conducted on the ground level. Surveyor and Maintenance Director Staff #9 walked down to the far end of the hallway. Maintenance Director #9 opened the stairwell door and the single low 2-note chime sounded; however, the light located on the ceiling at the nurses ' station failed to light. Surveyor walked to the nurses ' station and stood underneath the light and Maintenance Director #9 repeated opening the door. Surveyor could not hear the 2-tone chime alarm and the light failed to come on. Maintenance Director #9 walked past the surveyor to the opposite ground floor hallway and repeated the observation on the other stairwell door. The other indicator light failed to light on the ceiling when the door was opened. Surveyor noted nursing Staff # 16 and #11 were at the nursing station. Surveyor asked Maintenance Director #9 to hold the stairwell door open again, but not to close it until signaled. When the door was opened, and the surveyor noted the nurses remained in their same positions, they were approached and interviewed. The nurses were asked if they knew when the stairwell doors at the ends of the unit were opened. Nurse #16 stated that an alarm would sound, and the indicator lights nearby would light up. When asked what they would do if the saw the indicator light and heard the door alarm, Nurse # 11 stated that they would get up and check the area where the sound was coming from. Nurse #16 added that they always would check. The nurses were asked if they currently heard the sound from the exit door. They replied that they did not. When asked if they were aware that both stairwell doors were opened and closed several times in the past few minutes, and the indicator lights did not function they both said, no. Both nurses were informed that a staff member was holding one of the stairwell doors open and asked if they could see the indicator lights on the ceiling. Nurse #16 replied that the light was not working, picked up the phone asked the receptionist to send Staff #9 to the unit. Nurse #11 replied s/he did not realize the lights were out. Surveyor shared observations regarding the location of the two door open indicator lights located in the hallway near the nurses ' station and their proximity to indicator lights for residents ' call bell to Staff # 9, #11, and #16. Staff #11 and #16 stated that it would be difficult to determine if the light was for the call bell or door exits. Further observation of the ground floor unit on [DATE] at 11:39 AM revealed an unlocked stairwell Door #3 located across from the nursing station. It was ajar and not fully engaged into the doorway frame. No wanderguard alarm system device or a door open alarm was found on either side of the doorframe. When asked, Maintenance Director #9 stated that the door must be pushed closed. He demonstrated by going into the stairwell and pushed the door closed. He reopened the door. Surveyor noted that the unlocked opened door had two flights of stairs leading down. Maintenance Director #9 responded that the steps led to the basement level. There were no resident rooms in the basement, however, the maintenance, laundry and housekeeping departments were stationed there. Surveyor and Maintenance Director #9 proceeded out through the ground floor stairway door #3 and down two flights of steps to the basement level stairway door #4. Surveyor noted door #4 was propped open at its bottom with a yellow wedge. When surveyor acknowledged the door, Staff #9 removed the wedge and stated the door was kept open because the area was being cleaned. However, no cleaning supplies, tools or janitorial staff were found in the area. Observation of the basement level ' s exit leading doors were conducted at 11:43 AM. Observations of the employee exit door #5 revealed a wanderer/elopement indicator device. Staff #9 explained that anyone without a wander guard would be able to exit the door without activating the alarm. Staff #9 opened the employees ' exit door #5 however, no alarm sounded or announcements were heard. The surveyor followed him to the other end the corridor to an exterior leading exit door (Door #6) with a horizontal door release on it. Surveyor observed asStaff #9 pushed the door release and held it open for the surveyor. No alarm sounded or any announcements were heard. Surveyor noted this second door, exited directly outside to a flight of six cement steps without railing that led up to the facility ' s parking lot located in the far-left side of the facility. When asked why the employee exit door alarms did not activate, Staff #9 replied that every day from 5:30 AM to 07:00 PM, the system is scheduled to deactivate the wanderguard detection alarms and the accompanied exterior leading exit doors like Door #6 to allow staff free access in and out of the facility from this area without consistent activation of the alarm system throughout the day. He added that anyone without a wanderguard device would be able to exit through the two doors just observed undetected. At 11:48 AM, continued observations of the basement doors revealed 4 additional doors without alarming devices as well as stairwell doors on the ground floor and 2nd floor nursing units revealed no wanderguard alarming devices. Surveyors spoke with the DON and the ADON on [DATE] at 12:30 PM regarding the concerns noted during the observations. The DON and ADON denied having knowledge of the daily deactivation of the wanderer/elopement alarm system The surveyor conducted an interview with the DON and Assistant Director of Nursing (ADON) on [DATE] at 10:35 AM. The DON was asked about the investigation conducted regarding Resident #10 leaving out of the building on [DATE]. The DON stated the staff informed them of the incident the same day. She added that the evening before, on [DATE], she conducted a Wandering/Elopement Assessment on Resident #10 and placed a wanderguard device on the resident and called back later from home to ensure that it was still on. When asked why the assessment was conducted, s/he indicated that after observing the resident, she felt an assessment would be warranted. Surveyor asked if s/he, or the ADON investigated the incident to determine how the resident made it out of the facility without the wanderguard alarm sensors going off. The DON responded that multiple calls were made to the facility by her/him and by the Administrator to ensure the resident had on their bracelet and each time the staff assured them that it was on. The device and the exit door sensors were tested but they were not able to determine how the resident made it through the basement without activating the exit doors sensors in the basement. When asked if a formal (QAPI) committee investigation was conducted regarding the elopement, s/he responded that the Administrator ensured everyone was aware of the incident by Monday [DATE]. Quality Assurance and Performance Improvement (QAPI) is a data-driven and proactive approach to quality improvement. QAPI activities involve members at all levels of the organization to: identify opportunities for improvement; address gaps in systems or processes; develop and implement an improvement or corrective plan; and continuously monitor effectiveness of interventions. However, review of the QAPI Committee meeting attendance sheets conducted on [DATE] at 11:30 AM failed to show that a meeting was conducted for the months of June and [DATE]. There was no evidence to support that the QAPI committee met regarding the elopement incident. During interviews conducted with QAPI members #3, #9, and #13, the members stated they had not attended a QAPI meeting for the months of June and [DATE]. Although there were daily weekday morning briefings, they denied knowledge of the [DATE] elopement and stated that their interviews with the survey team was the first time, they were made aware about the incident. The facility's initial plan of action to remove immediacy was submitted on[DATE] at 9:55 PM was rejected and returned. The second plan of action was submitted on [DATE] at 11:10 PM was rejected and returned. The third plan of action was submitted on [DATE] at 01:50 AM was rejected and returned. The fourth plan of action was submitted on [DATE] at 03:50 AM was rejected and returned. The fifth plan of action was submitted on [DATE] at 05:28 AM was rejected and returned. The final plan of action was received on [DATE] at 05:41 AM and accepted at 06:00 AM. After verification of the completion of the plan of action, the IJ was abated on [DATE] at 4:45 PM. After the IJ was abated, the facility continued with deficient practice and the scope and severity was lowered to a D. The plan of action was as follows: 1) Residents # 9 and # 10 no longer reside in the building. The DON, ADON and the MDS Coordinators reviewed all current residents for wander guard/elopement and implemented safety interventions for those residents found at risk. 2) An audit of current residents for wandering/elopement was conducted by the DON, ADON and MDS Coordinators. Audits will be conducted weekly by the DON, ADON and the MDS Coordinators times 4, then monthly as well as reviewed monthly in the QAPI meetings and in weekly risk meetings with the Medical Director. 3) Wandering /Elopement assessment on all new admissions will be immediately completed by the charge nurses and reviewed by the DON, ADON and the MDS Coordinators at that time and will be reviewed monthly during the QAPI meetings. Facility is to provide immediate training to all facility staff including all contract staff and new hired personnel. 4) Facility Maintenance Director and Corporate Vendors conducting on site audit and review of failed security alarm systems, system doors , and light indicators. All failed systems will be repaired by facility Maintenance Director with Corporate Vendor ' s assistance. 5) Maintenance will track and log system function weekly to ensure that all alarms, door, and light indicators are functioning properly. This will be reviewed by QAPI at monthly meetings ongoing.