Every finding on record at Complete Care at Annapolis

Based on record review, interview with residents, and the facility staff, it was determined that the facility failed to ensure that quarterly resident fund account statements were provided to residents. This was evident for four residents (Residents #86, # 1, #3 and #47) out of five residents reviewed for personal funds during the facility's recertification survey.The findings include:On 03/06/2026 at 7:45 AM, during the initial tour of the facility, some residents provided statements regarding quarterly statement of account as follows.On 03/03/2026 at 9:09 AM, Resident #86 stated that he/she did not receive a quarterly statement.On 03/03/2026 at 9:42 AM, Resident#1 stated that he/she had an account with the facility but had never received statements and requested that statements be provided.On 03/03/2026 at 10:05 AM, Resident #3 stated that he/she had never received a statement of account.On 03/03/2026 at 11:55 AM, Resident #47 stated that he/she did not always receive quarterly fund statements.On 03/06/2026 at 10:11 AM, the surveyor requested that the Business Office Manager (BOM) provide a list of residents with accounts at the facility.On 03/06/2026 at 10:26 AM, the list was provided and reviewed.On 03/06/2026 at 10:33 AM, in an interview with the BOM, when asked how statements were given to residents, she stated that statements were given monthly to residents who requested them and quarterly to all other residents. When asked if records of distributed statements were maintained, she stated that a binder was maintained for this purpose, which the surveyor requested for review.On 03/06/2026 at 11:12 AM, in a follow-up interview with the BOM, when asked for the facility's protocol for providing statements, she stated that residents or their responsible parties were to sign a copy of the receipt as acknowledgment of receiving the statement.On 03/06/2026 at 11:15 AM, the surveyor reviewed the statements for residents who reported not receiving them. The review failed to show acknowledgments that residents had received the statements. The BOM confirmed that there was no evidence that the residents had received the quarterly statements.On 03/06/2026 at 11:24 AM, in an interview with the Nursing Home Administrator (NHA), when asked about the process for providing quarterly statements to residents or responsible parties, he stated that statements were provided in person to capable residents and mailed or emailed to residents with responsible parties quarterly or per request and acknowledged copies were kept.On 03/06/2026 at 11:26 AM, when informed of the concerns regarding the failure to provide quarterly statements to residents, the NHA acknowledged the concern.

Based on interviews and medical record review, it was determined that the facility staff failed to provide oral hygiene care and showers to dependent residents. This was evident for 2 (Resident #93 and #86) out of 3 residents reviewed for Activities of Daily Living (ADL) care during the annual survey.The findings include:1). On 3/03/2026 at 8:39 AM, an interview with Resident #93 was conducted. They reported that no one at the facility cleaned their teeth and that a family member came in to the facility to assist with oral hygiene once a week. On 3/04/2026 at 12:02 PM, a review of Resident #93's medical records was conducted. The review revealed Minimum Data Set (MDS) Section GG that indicated the resident required partial/moderate assistance to perform oral hygiene. Further review of the resident's care plan indicated that the resident had an ADL self-care deficit related to fatigue and tremors to upper extremities. It also stated that the resident required extensive assistance to maximize independence.On 3/04/2026 at 1:10 PM, a follow up interview with Resident #93 was conducted. When asked if they had received oral care in the morning, the resident stated no. On 3/04/2026 at 1:19 PM, a review of Resident #93's electronic record was conducted. The review revealed a task titled oral hygiene that had several shifts documented as not applicable.On 3/04/2026 at 1:27 PM, an interview with Staff #17 was conducted. When asked if she had provided oral care to Resident #93, the staff replied no. She further explained that she had to provide residents with their lunch trays first and therefore she had not had a chance to provide oral care to the resident. On 3/04/2026 at 1:43 PM, the facility was asked to provide documentation that Resident #93 was provided with oral hygiene. On 3/04/2026 at 1:51 PM, an interview with the Director of Nursing (DON) was conducted. When asked what not applicable under oral hygiene meant, she stated she was not aware. She further stated that Geriatric Nursing Assistants (GNAs) also document provision of oral care under oral care task. The surveyor asked for documentation on oral care provided to the resident in the last 30 days as well as the facility's oral care policy. On 3/05/2026 at 7:12 AM, a follow up interview with the DON was conducted. She stated that the facility's oral policy does not specify the frequency in which oral hygiene or oral care should be provided to residents. However, it was the facility's protocol to provide residents with oral hygiene twice a day, in the morning and at night. On 3/05/2026 at 7:40 AM, the surveyor was provided with Resident #93's oral care documentation for the last 30 days. The review was conducted with the DON present. 7 (2/14, 2/15, 2/18, 2/27, 2/28, 3/1 and 3/4) out of the 30 days, Resident #93 was not provided oral care per facility's protocol. On 3/05/2026 at 7:44 AM, the DON was made aware of the oral care concerns. 2). On 3/03/2026 at 9:17 AM, an interview with Resident #86 was conducted. They reported that they had not had a shower for the last 5 weeks. They also added that they would like to get showers more often if given an opportunity. On 3/04/2026 at 8:01 AM, a review of Resident #86's medical record was conducted. The review revealed a care plan that indicated the resident had a self-care performance deficit related to limited mobility. The care plan also indicate that Resident #86 was totally dependent on staff to provide showers on preferred days.A review of the unit's shower schedule indicated that Resident #86 was supposed to get showers on Mondays and Thursdays. Further review of Resident #86's MDS Section GG, revealed that the resident was coded for partial/Moderate assist for showers. Under section F, for resident preferences, it was coded that it was very important for Resident # 86 to choose between shower and bed bath. On 3/05/2026 at 8:00 AM, the facility was asked to provide evidence that Resident #86 was offered or given a shower for the last 30 days.On 3/05/2026 at 8:50 AM, the facility provided shower document records from 2/5/2026 to 3/5/2026. The review of these records indicated that Resident #86 had showered once (2/9/2026) for the last 30 days. On 3/05/2026 at 9:08 AM, an interview with Staff #14 was conducted. She reported that it was the responsibility of Geriatric Nurse Assistants (GNAs) to offer and provide showers to residents. She also confirmed that in the last 30 days, she had never given Resident #86 a shower or assisted a GNA with providing the resident with a shower.On 3/05/2026 at 9:28 AM, the Facility Administrator was notified of the showers concern.

Based on observations and staff interview, it was determined that the facility failed to store food products in accordance with professional standards for food safety. This was evident in 3 out of 3 food storage areas observed during the initial Kitchen tour.The findings include:On 3/03/2026 at 7:43 AM, an initial tour of the kitchen with the Food Service Director was conducted. A Turkey Gravy Mix was observed without an expiration date, though the received date of 2/23/2026 was printed on it. Other non-perishable items without expiration dates included a bottle of maple syrup. Perishable items found without expiration dates included 1 bag of frozen corn dogs, 1 bag of frozen meatballs, and a container of garlic. 4 bags of bread rolls, each containing about 12 rolls, were observed with an expiration date of 2/26/2026. A bottle of Teriyaki sauce had an expiration date of November 2025. A container of peeled boiled eggs had an expiration date of 2/26/2026. The Food Service Director threw out all expired items.On 3/03/2026 at 7:45 Am, during the brief tour of the fridge, the surveyor observed 6 containers with cooked foods. These containers did not have a label to identify the cooked items as well as no date to discard the foods. A follow up interview was conducted with the Food Service Director. When asked if the cooked foods should be labeled, she stated yes, that it was the facility's protocol to write what the name of the cooked item as well as the expiration or use by date. On 3/04/2026 at 8:05 Am, the surveyor notified the facility administrator of the food labeling and storage concerns identified during the kitchen tour.

Based on observations, interviews and record reviews, it was determined that the facility failed to provide residents' food in accordance with the resident's preferences. This was evident for 2 (Resident #8 and #39) out 4 residents reviewed for dining during the annual survey. The findings include:1). On 3/06/2026 at 12:48 PM, Resident #8's lunch meal was observed. The surveyor noted that the portions of meals were regular. The lunch meal ticket was reviewed and indicated that the resident was to be served large portions. On 3/06/2026 at 12:50 PM, a brief interview with Resident #8 was conducted. They reported that the meal ticket do not match what is served. When asked how often it occurred, the resident replied, so many times.On 3/06/2026 at 1:22 PM, an interview with the Staff #25, the facility's Food Director, was conducted. The surveyor showed Staff #25 the meal portions served to Resident #8. When asked if the portions were considered large as indicated on the meal ticket, the staff confirmed that the food portions served were regular and not large. 2). On 3/06/2026 at 12:52 PM, another dining observation was conducted. Resident #39's meal ticket was reviewed, it stated to serve green beans and do not serve peas. The meal served to Resident #39 included peas and carrots, no green beans were observed. On 3/06/2026 at 12:55 PM, a brief interview with Resident #39 was conducted. When asked if they had eaten the peas and carrots, the resident said no. On 3/06/2026 at 12:57 PM, another interview with Staff #14 was conducted. Staff confirmed that Resident #39 was not served green beans for lunch. She also confirmed that the meal ticket indicated that the resident should not be served peas. On 3/09/2026 at 10:56 AM, another interview with Staff #25 was conducted. When asked who was responsible for updating the resident's meal preferences, she stated that it was the dietician responsibility. She also stated that if a resident had a pattern of refusing certain meals or portions, it was the facility's expectation to honor the meal preferences and update the meal tickets as soon as possible. On 3/09/2026 at 1:32 PM, the Director of Nursing (DON) was notified of the meal preferences concerns.

Based on interviews, observations and record reviews, it was determined that the facility failed to revise residents care plan in a timely manner and implement the care plan interventions. This was evident for 2 (Resident #93 and #8) out of 2 residents reviewed for falls during the annual survey. The findings include:A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.1). On 3/03/2026 at 8:39 AM, an interview with Resident #93 was conducted. They reported that they fell a while ago. During the interview, the surveyor observed the bed to be in a high position. On 3/04/2026 at 1:10 PM, the surveyor observed Resident #93's bed in a high position when interviewing the resident regarding their oral care.On 3/05/2026 at 11:39 AM, a review of Resident #93's medical records was conducted. The review revealed that the resident had an actual fall on 1/13/2025. Further review of the care plan revealed a statement that indicated Resident #93 was at high risk for falls related to deconditioning and history of multiple falls. The interventions included neuro-checks to be completed. On 3/06/2026 at 7:55 AM, an interview with the unit manager was conducted. She reported that the resident is at risk for falls. When asked what interventions were implemented to prevent future falls, staff replied that the call bell should be near the resident and staff rounds. At this time, the surveyor pointed out that Resident #93's bed was in a high position. On 3/06/2026 at 8:20 AM, a review of the facility's fall prevention policy was conducted. The review indicated that residents who were identified as low/moderate fall risk should have the bed locked and lowered to a level that allowed resident's feet to be flat on the floor when sitting on the edge of the bed. For residents identified as high fall risk, additional interventions included increased frequency of rounds, low bed, floor mat and assess the room configuration.On 3/06/2026 at 8:55 AM, the facility was asked to provide evidence that neuro-checks were completed after Resident #93 fell as indicated on the care plan interventions. On 3/06/2026 at 10:21 AM, an interview with the Director of Nursing (DON) conducted. She reported that there was no evidence that the neuro-checks were done. When asked what the expectations were on updating the care plan, she stated that the care plans should be revised immediately or as soon as possible after a fall occurs. The DON also clarified that the care plan revisions should have included to keep Resident #93's bed in the lowest position and wheels locked. 2). On 3/03/2026 at 9:24 AM, an interview with Resident # 8 was conducted. The resident reported that they fell off the bed in January 2026, fractured their hip and were sent to the hospital.On 3/04/2026 at 8:50 AM, a review of Resident #8's medical records was conducted. The review revealed that the resident had an unwitnessed fall on 1/6/2026. Records also indicated that the resident was on a blood thinner medication called Plavix. Review of the care plan indicated revisions that were made 3 days after the fall, on 1/9/2026. The interventions stated, continue with at risk plans and to perform neuro-checks per facility policy.On 3/04/2026 at 9:20 AM, the facility was asked to provide evidence that the neuro-checks were completed after the resident's fall incident.On 3/06/2026 at 10:54 AM, an interview with the DON was conducted. When asked what actions should be taken after a resident falls, the DON reported that a post fall assessment should be completed, care plan should be updated, vitals signs and neurological assessment should be completed per facility's protocol. She further stated that it was the facility's protocol to perform neuro-checks for any resident who has had an unwitnessed fall. The DON added that there was no evidence to indicate that neuro checks were completed after Resident #8 fell. Additionally, she also acknowledged that the care plan revisions were not revised in a timely manner.On 3/06/2026 at 11:04 AM, at this time the surveyor discussed with the DON concerns with care plan revisions and failure to implement the post fall interventions as indicated on the care plan.

Based on interviews and observations it was determined that the facility failed to utilize Video Remote Interpreting (VRI) services to communicate with deaf residents. This was evident for 1 (Resident #47) out of 4 residents reviewed for communication-sensory impairment during the annual survey. Video Remote Interpreting (VRI) is a service that uses video technology to connect a deaf or hard of hearing person with a sign language interpreter who appears on a screen (tablet, computer, or monitor). The interpreter signs what the staff say and voices what the resident signs so both sides can understand each other. The findings include: On 03/03/2026 at 8:25 AM, the surveyor observed a sign outside Resident #47's room indicating that the resident was deaf. At the same time, an interview with Geriatric Nurse Assistant (Staff #7), revealed that she communicated with Resident #47 through written communication. On 03/03/2026 at 9:13 AM, an interview with Geriatric Nurse Assistant (Staff #8), revealed that she communicated with Resident #47 through written communication. On 03/03/2026 at 12:10 PM, an interview with Resident #47 revealed that written communication was not the resident's preferred method of communication. At the same time, an observation of the Resident #47's room revealed that there was a VRI tablet in the room. On 03/05/2026 at 8:05 AM, an interview with Licensed Practical Nurse (Staff #14) revealed that her form of communication with Resident #47 was through facial expressions and writing. It was also revealed that staff rarely used the VRI tablet in the resident's room. On 03/05/2026 at 8:08 AM, an interview with Resident #47 revealed that staff rarely use the VRI tablet as a form of communication. On 03/05/2026 at 9:53 AM, an interview with the Director of Nursing revealed that the expectation was that staff use the VRI system in place for Resident #47 throughout the day during care. On 03/05/2026 at 11:34 AM, surveyor requested Geriatric Nurse Assistant (Staff #8) to obtain an interpreter on the VRI system; however, Staff #8 was unable to do so because she did not know how to use the system. On 03/05/2026 at 11:37 AM, the surveyor requested Licensed Practical Nurse (Staff #14) to obtain an interpreter through the VRI system, and Staff #14 was unable to do so. On 03/05/2026 at 1:09 PM, the concern was reviewed with the Assistant Director of Nursing and she indicated that she understood.

Based on observation, record review, and staff interview, it was determined that the facility failed to ensure that oxygen administration equipment was dated and labeled after being changed in accordance with physician orders and facility expectations. This was evident for 2 (Residents #109 and #20) out of 2 residents reviewed for oxygen therapy during the facility's recertification/complaint survey. The findings include: On 03/03/2026 at 7:59 AM, during the initial tour of the facility, Resident #109 was observed eating breakfast in bed. The resident was receiving oxygen at 2 LPM via nasal cannula. The nasal cannula tubing was observed without a date or label.On 03/03/2026 at 8:11 AM, during the continued tour, Resident #20 was observed in bed preparing to eat breakfast. The resident was receiving oxygen at approximately 1.8 LPM via nasal cannula. The nasal cannula tubing was observed without a date or label.On 03/04/2026 at 7:27 AM, a review of the physician's orders for Resident #20 indicated an order for oxygen at 2 L/min via nasal cannula as needed for shortness of breath (SOB). The order also indicated that the oxygen humidifier bottle and tubing were to be changed weekly and as needed if visibly soiled, and that each component be labeled with the date and staff initials, scheduled every Sunday on the night shift.On 03/04/2026 at 7:33 AM, a review of the physician's orders for Resident #109 indicated an order for oxygen at 2 L/min via nasal cannula continuously for COPD. The order also indicated that the oxygen humidifier bottle and tubing were to be changed weekly and that each component be labeled with the date and staff initials, scheduled every Sunday on the night shift.On 03/04/2026 at 9:47 AM, during a follow-up observation, Resident #109 was observed in bed receiving continuous oxygen at 2 LPM via nasal cannula. The nasal cannula tubing remained without a date or label.On 03/04/2026 at 10:13 AM, during an interview with the Unit 1 Manager, Licensed Practical Nurse (LPN #10), when asked if she had received training on administration of oxygen and care for oxygen equipment, she confirmed that she had received training on oxygen administration. When asked about the expectations regarding oxygen tubing and humidifiers, she stated that they should be changed weekly and as needed. When asked what should occur after changing the tubing, she stated that the equipment should be dated and labeled.On 03/04/2026 at 10:18 AM, during a follow-up observation of Resident #20, the nasal cannula tubing was observed without a date or label.On 03/04/2026 at 10:19 AM, LPN #10 was asked to perform a dual observation with the resident and was asked when the nasal cannula tubing was last changed. She stated that she could not determine when it was last changed because there was no date on the nasal tubing. She stated that the nasal tubing would be changed and dated.On 03/04/2026 at 10:21 AM, during an interview with Registered Nurse (RN #11) who was present during the observation, the RN stated that the expectation for care of oxygen equipment, specifically nasal cannula tubing, was that it should be changed weekly and dated.On 03/04/2026 at 12:39 PM, during an interview with the Director of Nursing (DON), she stated that the expectation for oxygen equipment was that tubing should be changed weekly on Sundays and dated after each change.On 03/04/2026 at 12:41 PM, when informed of the concern regarding oxygen tubing not being dated or labeled, the DON acknowledged the concern.

Based on resident interview, record review, and staff interview, it was determined that the facility failed to administer time sensitive medication on time. This was evident for 1 (Resident #108) out of 7 residents reviewed during the recertification survey. The findings include: On 3/03/2026 at 9:53 AM, an interview with Resident #108 was conducted. The resident complained that the facility staff administered their seizure medications late.On 3/10/2026 at 9:30 AM, a review of the Medication Administration Audit was conducted. The audit revealed that Levetiracetam oral tablet 1000 mg, an anticonvulsant, was ordered to be given by mouth on 3/1/2026 at 9 PM and was given on 3/2/2026 at 9:24 AM by Staff #26. Lamotrigine oral tablet 150 mg, an anticonvulsant, was ordered to be given on 3/6/2026 at 5 PM and was given on 3/6/2026 at 8:25 PM by Staff #27. Levetiracetam oral tablet 1000 mg was ordered to be given by mouth on 3/7/2026 at 9 PM and was given on 3/7/2026 at 10:15 PM by Staff #18.Lamotrigine is a time-sensitive medication that requires strict adherence to a specific dosing and titration schedule to maintain safety and efficacy.The timely administration of Levetiracetam, or Keppra, is medically critical because of its relatively short half-life and the high risk of breakthrough seizures associated with inconsistent blood levels.On 3/10/2026 at 9:42 AM, an interview with the Director of Nursing (DON) was conducted. The surveyor made the DON aware of Resident #108's concern with the timing of medication administration. The surveyor reviewed the findings from the Medication Administration Audit with the DON and confirmed the findings. The DON stated that they received a request from the resident recently to adjust the medication times because the staff was not administering the medications on time. The DON stated that the medication was given late and the nursing staff is expected to give medications in a window of 1 hour before to 1 hour after the due time.

Based on medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#65) of 2 residents reviewed for hospitalization during a recertification/complaint survey. The findings include: During an initial screen of Resident #65 on 12/5/2024 at 7:51 AM, the resident stated that s/he was recently hospitalized . On 12/5/2024 at 8:48 AM a review of nurses' progress notes and change in condition documentation dated 12/1/2024 at 7:16 AM revealed Resident #65 was sent to the ER (emergency room ) via 911 on 12/1/2024 for altered mental status. However, there was no documentation/evidence that the resident and/or daughter was notified in writing the reason for transfer to the hospital. On 12/5/2024 at 9:15 AM an interview was conducted with Licensed Practical Nurse (LPN #14). Regarding written notification of reason for transfer to the hospital, LPN #14 stated that the reason for transfer was documented in the change in condition form included in the transfer packet sent with the resident to the hospital. She stated that the residents were notified verbally of the reason for transfer to the hospital. LPN #14 added that family members/RP (Resident Representative) were notified of reason for transfer verbally in person if they were present in the building, and over the phone if they were not present. She confirmed that she has not given in writing the reason for transfer to the hospital to any resident and/or their RP. On 12/5/2024 at 9:27 AM, in an interview with Licensed Practical Nurse (LPN #13) who has worked in the facility for over 6 years, she confirmed that she has never given any resident and/or their RP the reason for transfer to the hospital in writing. On 12/5/2024 at 9:35 AM, a follow up interview was conducted with Resident #65. The resident stated that s/he was told verbally the reason for the transfer to the hospital but s/he was not given anything in writing regarding the reason for transfer. On 12/5/2024 at 11:09 AM, an interview was held with the Director of Nursing (DON). DON stated that the reason for transfer was documented in the transfer form sent with the resident to the hospital. She added that a copy of the transfer form was later mailed to the RP by the Nursing Home Administrator. When asked to provide a copy of the transfer notice that was mailed to Resident #65's RP, DON stated that she could not find any documentation to show that the resident and/or their RP were given in writing the reason for transfer to the hospital on 12/1/2024. She further confirmed that they did not mail the transfer form that had the reason for transfer to the hospital to the RP because Resident #65 returned to the facility within 24 hours.

Based on medical record review, staff interview, and observation, it was determined that the facility staff failed to provide an activities program to meet the needs and preferences of residents by 1) not performing activities with residents per care plan and 2) not documenting care plan activities. This was evident for 1 resident (Resident #31) reviewed during the Medicare/Medicaid recertification survey. The findings include: On 12/04/24 at 11:29 AM, during a phone interview with Resident #31's mother, she told the surveyor that Resident #31 had activities as part of his/her care plan, but the activity staff had not seen him/her. On 12/06/24 at 9:01 AM, the surveyor reviewed the electronic record for the resident and the care plan showed that Resident #31 had little, or no activity involvement related to physical limitations initiated on 05/06/2022, the goal was that Resident #31 will participate in activities of choice while in the room due to physical limitations and was revised on: 08/06/2024 with a target date of 11/30/2024. It also showed the intervention which was that the activity staff will have one-on-one in-room activities/ music therapy once a day and 3 times every week. The surveyor reviewed the activity log in the electronic record but could not find any activity documentation. On the same day at 09:06 AM, in an interview with the unit manager Staff #8, when asked about how activities were done and the type of activities done with Resident #31, she stated that the activity staff just goes into the room to look at the resident and does not know the type of activities done with the resident. On the same day at 09:14 AM, in an interview with the Activities Director Staff#10, she was asked about the activities done with the Resident#31, she stated that she provides music therapy as well as reading the daily news to him/her. She stated that the activity was one-on-one. She also stated that it should have been done 3 times per week according to Resident #31's care plan but it was not consistent. When she was asked how activities were documented, she told the surveyor that the activity done with all residents was noted in a participation log sheet while the activity was ongoing, then it would be transferred into the activity log in Point Click Care (PCC) an electronic record and the log sheet would be shredded afterwards. When she was asked for a 3-month activity log sheet for the resident, she stated that there had been no documentation of the one-on-one activities done with the resident and added that going forward, she would ensure that she and other activity staff members perform the activities with the resident and document it appropriately. 12/06/2024 at 9:28 AM, the surveyor informed the Director of Nursing about the concerns with Resident #31's activities and documentation.

Based on medical record review and staff interview it was determined the facility staff failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 1 (#65) of 2 residents reviewed for hospitalization during a recertification/complaint survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization . During an initial screen of Resident #65 on 12/5/2024 at 7:51 AM, the resident stated that s/he was recently hospitalized . On 12/5/2024 at 8:48 AM a review of nurses' progress notes revealed a change in condition documentation dated 12/1/2024 at 7:16 AM that noted Resident #65 was sent to the ER (emergency room ) via 911 on 12/1/2024 for altered mental status. Further review of the change in condition form revealed Resident #65's daughter was present at time of transfer to the hospital. However, there was no documentation and/or evidence in the record indicating that the facility staff notified the resident/resident's representative (RP) in writing of the facility's bed hold policy. On 12/5/2024 at 9:15 AM an interview was conducted with Licensed Practical Nurse (LPN #14). Regarding bed hold, LPN #14 stated that the facility's bed hold policy was included in the transfer packet given to the 911 transporters when a resident was being sent to the hospital. She stated that residents were informed verbally about the bed hold policy. LPN #14 confirmed that s/he has never given any written bed hold policy notification to a resident and/or their representative (RP) upon transfer to the hospital. On 12/5/2024 at 9:27 AM, an interview was held with Licensed Practical Nurse (LPN #13) who has worked in the facility for over 6 years. Regarding bed hold notification, LPN #13 stated that she has never given residents and/or their RPs a copy of the bed hold notification upon transfer to the hospital. She stated that the bed hold policy was included in the transfer packet sent to the hospital upon transfer but not given to the resident and/or their RP. However, LPN #13 added that the resident and RP were notified verbally of the bed hold policy. On 12/5/2024 at 9:35 AM, in a follow up interview with Resident #65, the resident stated that s/he was not given any written notification of the facility's bed hold policy. However, Resident #65 affirmed that s/he was readmitted to their same room upon return to the facility. On 12/5/2024 at 11:09 AM, an interview was held with the Director of Nursing (DON). DON stated that the facility's bed hold policy was usually sent with the transfer packet to the hospital and a copy mailed to the RP by the Nursing Home Administrator (NHA). When asked to provide a copy of the bed hold notification that was mailed to Resident #65's RP when the resident was transferred to the hospital on 12/1/2024, DON stated that she could not find any documentation to show that the resident and/or their RP were given any written notification of the bed hold policy. Surveyor reviewed the change in condition and transfer form with checklist sent with Resident #65 on 12/1/2024: DON confirmed that both did not indicate that the bed hold policy was included in the packet. On 12/5/2024 at 12:50 PM, in a follow up interview with the DON, surveyor shared concerns regarding written notifications of bed hold upon transfer/discharge of a resident to the hospital. DON stated that she has done her audits and Resident #65 was the only resident they missed giving the transfer notice and bed hold policy to.

Based on review of facility reported incident investigation and interview, it was determined the facility staff failed to 1) report an alleged violation (elopement) within 2 hours to the regulatory agency, the Office of Health Care Quality and 2) report an allegation of abuse in a timely manner to the state agency, immediately, but not later than two hours after the allegation is made. This was evident for 2 residents (#83 and #98) of 2 residents reviewed for timely reporting an alleged violation during a recertification/complaint survey. The findings include: The Brief Interview for Mental Status (BIMS) score is a number between 0 and 15 that indicates a person's cognitive health: 13-15 points: The person's cognition is intact; 8-12 points: The person has moderate cognitive impairment; 0-7 points: The person has severe cognitive impairment. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. 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 1) On 12/6/2024 at 1:36 PM, review of the investigation report of Facility Reported Incident (FRI), MD00205317, revealed that on 5/2/2024 shortly after shift change, the GNA (Geriatric Nursing Assistant) noted that Resident # 98 was not in their room. Resident #98 was last seen in room at approximately 6:30 AM. Per the report, staff became aware on 5/2/2024 at 6:56 AM and the local police department was notified of a missing resident at 7:20 AM. Further review of the investigation report of the FRI revealed the resident later returned to the facility at 8:30 AM. However, a review of the email confirmation of the initial incident report revealed that it was submitted to OHCQ on 5/2/2024 at 5:23 PM, thus failing to meet the 2 hours reporting requirements for any alleged violations. On 12/9/2024 at 8:55 AM, a review of Resident #98's admission MDS (Minimum Data Set, a standardized assessment tool that measures health status in nursing home residents) with ARD (Assessment Reference Date) of 4/2/2024 revealed Resident #98 had a BIMS score of 01 (severe cognitive impairment). On 12/9/2024 at 9:20 AM, a review of Resident #98's care plan revealed the resident was care planned for being at risk of elopement/wanderer r/t impaired safety awareness, Resident wanders aimlessly, initiated on 4/29/2024. On 12/10/2024 at 10:00 AM interview conducted with the Nursing Home Administrator (NHA): NHA confirmed that the initial report was submitted to OHCQ on 5/2/2024 at 5:23 PM. NHA stated that when the resident returned to the facility, their focus was centered on the safety of the resident and all the other residents prior to submitting the report to OHCQ. On 12/11/2024 at 1:21 PM in an interview with the Director of Nursing (DON) prior to survey exit, Surveyor reviewed the above FRI with her. DON was informed of surveyor's concerns regarding the facility's failure to timely report a resident elopement. No further information was provided. 51490 2) During review of a facility reported incident on 12/11/24 at 9:34am, it was found that an allegation of abuse was made by Resident #83 on 8/24/22 at 5:10am. The Self Report Form from the facility was submitted to the State Agency on 8/24/22 at 3:00pm by RN (Registered Nurse) staff #19. During an interview with the DON (Director of Nursing) on 12/6/24 at 1:00pm she verified the allegation of abuse should be reported within the two-hour time frame and stated the staff involved with the reporting of this citation no longer works in the facility.

Based on record review and staff interviews, it was determined that the facility failed to follow up with pharmacy recommendations after the monthly reviews were completed. This was evident for 2 (#56 and #10) of 5 residents reviewed for unnecessary medications during the recertification/complaint survey. The Findings include: Abnormal Involuntary Movement Scale (AIMS) evaluation is a 12-item rating evaluation scale use to assess the severity of abnormal movements which is a side effect of certain antipsychotic medications. On 12/5/24 at 9:36 AM: Review of Resident #56's monthly pharmacy review from September to December 2024 revealed that the pharmacist found some irregularities in September, November and December. Further review showed that September and November recommendation forms could not be found. The Director of Nursing (DON) was asked to provide the reports. On 12/5/24 at 9:46 AM Review of the Pharmacy Drug regimen review from January to December 2024 for resident #10 revealed irregularities for the months of August, October and December, the facility provided the December review form but did not provide the August and October review form, they were asked to provide it. On 12/5/24 at 10:26 AM, The DON provided the recommendation forms for Resident #56 and on review it showed that in the month of September (9/3/24) the pharmacist recommended: Abnormal Involuntary Movement Scale (AIMS) evaluation now and every 6 months Resident #56 was on Quetiapine (Seroquel) an antipsychotic medication use to treat Schizophrenia, bipolar disorder and depression. The Physician was not made aware of this recommendation, so it was never implemented. On 11/4/24, after the pharmacist completed the monthly medication regimen review (MRR), the pharmacist again recommended that the AIMS evaluation be done. On 12/5/24 at 10:26 AM, The DON also provided the October 2024 Pharmacy Recommendation forms for resident #10. Review of the forms revealed that the pharmacist recommended a fasting lipid panel for Resident #10 who was on Atorvastatin, a cholesterol lowering medication. This recommendation was never carried out until 12/2/24 when the pharmacist did another monthly review and recommended it again. Review of the Facilities MRR policy on 12/6/24 at 10:00 AM with revision date of 2/15/24 documented that the Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities within 30 days. On 12/06/24 at 9:15 AM in an Interview with the DON she was asked the process for carrying out pharmacy recommendations. She stated that the pharmacist once done with the reviews, would put their notes in (PCC) electronic record and then email a link to her and her assistant (ADON) to access. The Assistant Director of nursing (ADON) then prints out the recommendations and disperses them to the unit managers, The unit managers would talk with the physicians about the recommendations and get their feed back and signatures. The physicians would either agrees or disagrees with the recommendations to implement. This is then uploaded in the electronic records She stated that the ADON provides oversight to make sure all this was done. The ADON was asked in an interview on 12/06/24 at 9:20 AM the process for providing oversight. She stated that the unit Managers are responsible for making sure that Physicians see and address all recommendations before sending it to her. She double checks to make sure that recommendations were addressed before uploading. She was asked the time expectation for the physicians to see the recommendations and she said it's within 7 days but would need to verify the policy. She was made aware of the recommendations that were delayed and not carried out, she said she was aware of it and they're working on it

Based on observations, review of records and interview with facility staff and resident, it was determined that the facility failed to provide necessary respiratory care services for residents by failing to implement the physician order for a resident with tracheostomy. This was evident for 1 resident (Resident #54) reviewed for respiratory care during the Medicare/Medicaid recertification survey. The findings include: On 12/04/24 at 08:46 AM, during the initial tour of the facility, Resident #54 complained to the surveyor that his/her Passy-Muir valveSpeaking Valve (A Passy-Muir valve is a medical device that helps tracheostomy and ventilator patients communicate and maintain their airway) had not been changed since he/she got to the facility about one year ago. He/She added that he/she had a prescription from the Ear Nose and Throat (ENT) physician for a speaking valve since April 2024 and another prescription for the same valve and a tracheostomy collar in November 2024, but the facility had not replaced it. He/She provided a copy of the prescription to the surveyor. On 12/06/24 at 08:21 AM, in an interview with unit 1 manager Staff #8, she was asked about how Resident #54 gets his/her supplies for the tracheostomy. She told the surveyor that the resident visits the Ear Nose and Throat (ENT) physician monthly and after he/she returns from the appointment, she or the unit secretary/nurses checks for new recommendations/orders/prescriptions to be implemented. When she was asked how often the resident's speaking valve was replaced, she stated that the ENT physicians always give an order for replacement. She stated that she was not sure when the last valves were changed and that the facility had just ordered new valves because the resident's physician had recommended it recently. When she was informed about Resident #54's prescription for a clear speaking valve replacement since April 2024 and asked why it has not been implemented, she stated that she was aware of the prescription and had thought that the resident would get the supply through the respiratory therapist, but it turned out that the respiratory therapist does not give out supplies anymore. She added that the resident was given another prescription for the clear speaking valve and trach collar replacement in November 2024 and that the facility is waiting for the supplies to be delivered through the Administrator. On 12/06/24 at 08:48 AM, the surveyor notified the Director of Nursing about the concern identified and she stated that she was not aware that there was an issue with the supply. On the same day at 08:52 am, the Administrator was informed about the concern, and he stated that he became aware of both prescriptions on 12/06/2024 through the Resident #54's responsible party and that he placed an order for both immediately. He also stated that the supplies would be in the facility by the weekend.

Based on a facility reported incident, medical record review, and staff interview, it was determined that the facility staff failed to provide adequate supervision to a resident to prevent unsafe wandering/elopement. This was evident for 2 (#98, #29) of 2 residents reviewed for elopement during a recertification/complaint survey. The findings include: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. 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 A Wander guard bracelet is used to keep residents at risk of wandering/elopement comfortable and protected. It is discreet yet powerful, it triggers alarms and can lock monitored doors to prevent the resident leaving unattended. The Brief Interview for Mental Status (BIMS) score is a number between 0 and 15 that indicates a person's cognitive health: 13-15 points: The person's cognition is intact; 8-12 points: The person has moderate cognitive impairment; 0-7 points: The person has severe cognitive impairment. 1) On 12/6/2024 at 1:36 PM, review of the investigation report of Facility Reported Incident (FRI), MD00205317, revealed that on 5/2/2024 shortly after shift change, the GNA (Geriatric Nursing Assistant) noted that Resident # 98 was not in their room. Resident #98 was last seen in their room at approximately 6:30 AM. Per the report, staff became aware on 5/2/2024 at 6:56 AM and the local police department was notified of a missing resident at 7:20 AM. Further review of the investigation report of the FRI revealed Resident #98 later returned to the facility at 8:30 AM in very good spirits and indicated that s/he was hungry and went for a walk. The report further indicated that staff did not observe the resident leave their room/facility and described the resident as alert and oriented x1 (AO x1 means that a person knows who they are but not where they are, what time it is, or what is happening to them). Further review of the report revealed that all door alarms were functional and resident had a functioning device (wander guard) on their wrist, and suspicion was that Resident #98 climbed out of a room window. On 12/9/2024 at 8:55 AM, a review of Resident #98's admission MDS (Minimum Data Set, a standardized assessment tool that measures health status in nursing home residents) with ARD (Assessment Reference Date) of 4/2/2024 revealed Resident #98 had a BIMS score of 01 (severe cognitive impairment). On 12/9/2024 at 9:20 AM, a review of Resident #98's care plan revealed the resident was care planned for being at risk of elopement/wanderer r/t impaired safety awareness, Resident wanders aimlessly, initiated on 4/29/2024. On 12/10/2024 at 10:00 AM, in an interview with the Nursing Home Administrator (NHA), he confirmed that the resident left the building/facility without staff observation/knowledge and was gone for almost one and a half hours unaccounted for. NHA stated that one of the windows in the resident's room was partly opened and they suspected Resident #98 climbed out through that window. However, NHA stated that all the windows in the facility have now been secured with brackets that would not allow them to be opened past a certain level. He further stated that the exit doors were checked and all alarm doors were functional. He added that the resident's wander guard bracelet and those of the other residents in the building at the time were checked and they were all working properly. On 12/11/2024 at 1:21 PM in an interview with the Director of Nursing (DON), Surveyor reviewed the above FRI with her. Surveyor shared concerns regarding the facility's failure to supervise/prevent a resident with risk of wandering /elopement from leaving the building/facility. No new information was provided. 2) On 12/9/2024 at 11:15 AM, review of Facility Reported Incident MD00191220 revealed that on 4/11/2023 rehab staff observed Resident #29 sitting in a wheelchair on the sidewalk in close proximity to the front of the facility. When asked by the rehab staff how s/he got out, the resident pointed to the side door. Resident was escorted back inside and was not in any acute distress. The report indicated that upon reports that Resident #29 was observed outside of the facility, the Nursing Home Administrator (NHA) immediately checked the side door off Station 1 unit and found the door slightly ajar. On 12/9/2024 at 12:33 PM, review of Resident #29's medical records revealed a quarterly MDS with ARD of 5/4/2023 revealed the resident had a Brief interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. On 12/10/2024 at 9:37 AM, an interview was completed with the Nursing Home Administrator (NHA), he stated that the resident was wearing his/her wander guard which was intact and functioning. He stated that Resident #29 was the only resident with a wander guard at the time that was very mobile. However, he added that the alarm did not go off when the resident went out the door. When asked how the resident was able to exit the building with a wander guard in place, NHA stated the door malfunctioned. However, he added that facility staff manned the door until it was fixed by an outside vendor/technician. All doors were checked by the technician and were functioning correctly. NHA added that an elopement action plan was initiated, and continued safety checks were conducted and ongoing. On 12/11/2024 at 1:21 PM in an interview with the Director of Nursing (DON), Surveyor reviewed the above FRI with her. DON was informed of surveyor's concerns regarding the facility's failure to ensure that a cognitively impaired resident with exit seeking behaviors did not leave the building unauthorized. DON provided no new information regarding the deficient practice.

Based on observations, medication record review and interview with facility staff, it was determined that the facility failed to direct a resident (#45) to rinse their mouth after the administration of an inhaler as ordered by the physician. This occurred for one (Resident #45) of four residents observed during a medication observation during the recertification/complaint survey. The findings include: During medication observation on 12/10/24 at 9:22am, LPN (Licensed Practical Nurse) staff #16 administered Trelegy inhalation to Resident #45. Trelegy is a prescription medicine used long term to treat COPD (chronic obstructive pulmonary disease). Review of the medical record on 12/10/24 at 10:39am revealed a physician order dated 12/5/24 to administer Trelegy one inhalation Inhale orally (by mouth) one time a day for COPD. Rinse mouth after use. Staff #16 failed to instruct resident #45 to rinse his/her mouth after the inhalation of the Trelegy. During interview with the Director of Nursing on 12/10/24 at 12noon she verified the findings. She stated the nurse realized her error and she was in-service on reading the entire order prior to administration of medications.

Based on facility investigation documentation and medical records; observations and interviews, 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 7/19/20, 2) Provide adequate supervision to prevent the same resident from exiting the facility nine weeks later on 9/21/20, 3) Ensure all staff have been trained on how to check the functionality of the wander guard bracelets and how to obtain a new bracelet or replacement bracelet when necessary, 4) Educate all staff on the location and purpose of the elopement risk binder, and 5) Ensure external door usage on units where residents resided adhered to facility established procedures for use by staff during assigned duties to prevent resident elopement and to ensure resident safety. These actions resulted in the finding of an Immediate Jeopardy which was identified on 3/31/21 at 1:00 PM. This deficient practice was evident for 1 of 4 residents reviewed for elopement/wandering during a complaint survey (Resident #9). The facility submitted a plan for removal on 3/31/21 at 3:01 PM that was not accepted. The facility submitted a second plan on 3/31/21 at 3:53 PM and a third plan on 3/31/21 at 4:08 PM that was not accepted. On 3/31/21 at 5:20 PM the facility submitted a fourth plan of removal that was accepted on 3/31/21 at 6:00 PM. After determination of Immediate Jeopardy concerns, an extended survey was conducted. The Immediate Jeopardy was removed on 4/7/21 at 11:09 AM 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 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 #9's medical record on 3/29/21 at 8:00AM revealed the resident was admitted to the facility in May 2020 with diagnoses that included major depressive disorder, [CONDITION(S)], unspecified dementia w/behavioral disturbance, and severe manic episode with psychotic symptoms. On 03/29/21 a review of Resident #9's hospital discharge summary, dated 5/6/20, documented that the resident was sent to the hospital from another long term care facility for aggressive behavior. The resident's behavior was described as wandering and restless, and it was noted that the resident became aggressive with staff when they tried redirection as an intervention. On 03/29/21 a review of Resident #9's admission Minimum Data Set (MDS) assessment, with an assessment reference date of 5/13/20, coded that Resident #9 had a BIMS score of 3 under Section C, cognition. Section E, wandering, coded wandering occurred 1 to 3 days and answered yes to intrude on privacy of others. 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 03/29/21 a review of Resident #9's Elopement Risk Evaluation dated, 5/6/20, identified the resident was not at risk for elopement. This was inaccurate according to the hospital discharge summary dated 5/6/20 where it was documented that the resident wandered. A second Elopement Risk Evaluation, dated 5/14/20, was completed due to the resident displaying exit seeking behaviors as documented in a nursing note, dated 5/11/20 at 9:00 PM. The evaluation documented the resident was at risk for elopement due to past elopement attempts at home, attempting to leave the building without telling staff, wandering, and not accepting the situation. A one to one aide sat with the resident while the resident was displaying anxiety and a one-time order for medication was administered. On 5/14/20 a wander guard device was placed on Resident #9 and an order was written to check the functionality of the device on every day shift, and to check the placement of the wander guard on every shift. Further review of the medical record revealed documentation that the nursing staff would frequently have the resident at the nurse's station for 1:1 during times of anxiety and increased wandering. The facility did not initiate a formal care plan for Resident #9's wandering until 7/13/20. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 03/29/21 a review of facility reported incident MD 289 revealed that on 07/19/2020 at 5:32 AM, the facility's cook found Resident #9 outside of the building in the back parking lot. The resident was returned to the facility. The facility's investigation determined the resident removed the wander guard bracelet that was placed on the left ankle. On 3/29/21 at 7:08 AM LPN #33 stated, he/she removed the wander guard constantly. We don't know how because there were no scissors in the room and we couldn't find the wander guard. A psychiatric certified registered nurse practitioner (CRNP) note, dated 7/22/20 at 9:45 AM, documented, recommended either a transfer to a locked dementia unit for safety or 1:1 monitoring with continuous visual observation. The facility initiated 1:1 monitoring. 2) An interview was conducted with CRNP #26 on 3/30/21 at 10:58 AM. CRNP # 26 stated that she removed the 1:1 monitoring on 8/4/20 for the day shift because there were more staff around to monitor the resident, but left the resident on 1:1 monitoring for the evening shift. The CRNP stated that she discontinued the 1:1 monitoring for the evening and night shifts with the expectation that all shifts should monitor the resident hourly. A review of hourly monitoring sheets for August 2020 to November 2020 documented that the resident was monitored hourly. A review of a nurse's note, dated 8/20/20 at 10:27 AM, revealed staff documented, [Resident #9] observed in the lobby area approaching the receptionist area. When attempted to redirect, [the resident] stated [he/she] is trying to get out of here. A 9/18/2020 progress note documented that the IDT (interdisciplinary team) discussed use of the wander guard for Resident #9 as the resident was at risk to elope based on assessments. It was documented that the wander guard was checked daily every shift for function and placement. On 03/29/21 a review of a nurse's note, dated 9/21/20 at 11:30 PM, documented that the shift supervisor came and reported that the Resident #9 was found outside of the facility by a neighbor who called the police. On 03/29/21 a review of the facility's investigation of the 9/21/20 elopement revealed Resident #9 was outside of the facility at the back of the building. A neighbor rang the doorbell to the facility to inform staff that someone who looks like a patient was at the back of the building and 911 was called. It was documented that the wander guard was working when the paramedics brought the resident back in the building. Resident #9 was assessed from head to toe and there were no adverse findings. The facility staff continued hourly monitoring until the resident was transferred to another facility with a secure dementia unit. The Nursing Home Administrator (NHA) failed to notify the state agency of Resident #9's second elopement. On 3/29/21 at 9:10 AM the NHA (Nursing Home Administrator) was asked if the 9/21/20 elopement was reported to OHCQ (Office of Health Care Quality), the state regulatory agency. The NHA stated, No, he/she was found on facility property. The surveyor stated, But you reported the first one in July when dietary staff found the resident outside. The NHA stated, well he/she was on the property. The Surveyor stated, police and paramedics brought the resident back inside. The NHA stated, during change of shift at 10:30 PM he/she must have walked with someone leaving the building either at the front or the back door. The wander guard did not go off, but it went off when he/she came in the front door with the paramedics. I did not report it because I was told not to report it because he/she was still on the premises. The NHA stated this in front of 4 surveyors. An interview with the NHA on 3/29/21 at 10:11 AM revealed the facility's staff did not know how Resident #9 eloped on 7/19/20 or 9/22/20. On 3/29/21 at 7:08 AM an interview with Licensed Practical Nurse (LPN) #33 revealed the resident removed the wander guard constantly. LPN #33 stated staff did not know how the resident was removing the wander guard or how the resident got out of the building on 7/19/20 because the resident had been sitting in a chair by the nurse's station while the nurse passed medications. When the resident was returned to the unit the resident was not wearing a wander guard and staff could not find Resident #9 ' s wander guard. Review of the medical record on 3/29/21 at 8:30 AM revealed a skilled nurse's note dated, 6/2/20 at 8:33 AM, which documented the resident started aimless wandering at 4:30 AM and continued to go in and out of other resident's rooms and was very resistive to care. The note documented that the front desk was made aware that the resident did not have a wander guard on. On 3/30/21 at 7:19 AM LPN #33 stated that if the staff notices the wander guard was missing that the front desk would be notified. When asked why the front desk was notified, LPN stated, that is where wander guards are stored, and staff do not have access to the wander guards. LPN #33 was asked how the staff checked the functionality of the wander guards. LPN #33 stated that maintenance previously had the device to check the wander guard and that the device was not available on the unit prior to the elopement of 7/19/20. The device was now kept on the unit. 3) On 03/29/21 at 11:40 AM and interview was conducted with LPN #34 (LPN). LPN #34 stated she was unaware of who all the residents were that were an elopement risk, and she was unaware of an elopement binder. When LPN #34 was asked to demonstrate the use of the handheld device to check the function of the wander guard, LPN #34 was observed pressing all the buttons on the device and stated, it will come on as we get closer to a resident with a wander guard. LPN #34 went to the end of the hallway to Resident #21 and attempted to use the handheld device against Resident #21's right ankle. RN Unit manager #35 informed Staff #34 that Resident #21 did not have a wander guard on. Staff #34 placed the handheld device against the wander guard that was on Resident #20, however the device was not on. LPN #34 stated, We checked the wander guards this morning. It must be the batteries. RN Unit Manager #35 agreed and left the unit to get batteries. Unit manager #18 and RN Unit Manager #35 returned to the unit a few minutes later. Unit Manager #18 stated that the device did not need batteries. He stated, You just have to hold the power button down and it will turn on. Unit Manager #18 proceeded to demonstrate to LPN # 34 and RN Unit Manager #35 how to use the device. 4) Surveyors observed that Unit #2's nursing station did not have photos and names of elopement risk residents taped to the nursing station like Unit # 's nursing station. RN Unit Manager #35 was asked on 3/29/21 at 11:40 AM if there was a way to identify the elopement risk residents at the nurse's station. RN Unit Manager #35 looked around and said, I don't think so and then stated, Oh, we have this binder. It was the elopement binder. RN Unit Manager #35 was asked who was responsible for updating the elopement binder and RN Unit Manager #35 stated it was a team effort. A copy of the facility's elopement policy that was given to the surveyor on 3/29/21 at 9:10 AM for review. The policy stated, Once a resident is identified as being at risk for elopement, interventions are initiated. They may include: Placing a photo of the resident placed at the front reception area. The NHA stated on 3/29/21 at 9:10 AM that elopement binders were supposed to be at every nurses station, and the receptionist desk, and in the binders were pictures of all residents that were at risk for elopement. 5) The Maintenance Director was interviewed on 3/29/21 at 2:59 PM. The Maintenance Director stated, To my knowledge no one has used the exit doors, except the front door since COVID started. All staff enter and exit through the main door. My maintenance assistant changes the code on the doors on the keypad and no one has the code. The Maintenance Director was unaware that staff were using exit doors that were a potential point of egress for resident's at risk for elopement. Review of 8 pages of in-service training sign-in sheets that were given to the surveyor by the NHA on 3/29/21 at 9:20 AM revealed staff received training on ensuring complete closure of exit doors when leaving the building and re-directing patients who are at risk for elopement/wandering. Observation was made on 3/30/21 at 6:30 AM of Housekeeper #37 wheeling trash down the hall. The surveyor asked where she was going to take the trash, and Housekeeper #37 said she was going outside. The surveyor asked if she had the code to the door and the reply was, yes. The surveyor followed Housekeeper #37 down the hall and observed Housekeeper #37 punch a code in the keypad to the back exit door next to room #19 and #20. Housekeeper #37 exited the building with the trash and re-entered. This was the unit where Resident #9' s room was located as well as all current elopement risk residents. Geriatric Nursing Assistant (GNA) #44 was asked on 3/30/21 at 6:31 AM if she knew the codes to the doors in the unit and the reply was, yes. GNA #45 was asked on 3/30/21 at 6:33 AM if she knew the codes to the doors and the reply was, yes. Because of these findings, an Immediate Jeopardy was called on 3/31/21 at 1:00 PM. A final plan to remove the Immediate Jeopardy was submitted to the surveyors on 3/31/21 at 5:16 PM. Acceptance of the plan to abate the conditions that led to the Immediate Jeopardy occurred on 3/31/21at 6:00 PM. The Immediate Jeopardy was removed on 4/7/21 at 11:09 AM after the facility achieved 100% compliance in educating staff and putting processes in place. The facility's removal plan included the following provisions: 1. All residents at risk for elopement were reassessed for risk of elopement and the care plans were updated. This was for (4) residents. Two of the residents were moved off the hallway where the housekeepers take out the trash and were placed on the other side of the unit that was separated by 2 sets of doors that were kept closed. 2. Staff were educated to enter/exit through the front entrance of the facility. There was a sign on the back door that only housekeeping can use for trash removal and the side entrance into the kitchen would be a service entrance for any food deliveries. All staff were in-serviced on the elopement policy and procedure and the plan of correction. The facility achieved 100% compliance. 3. New hires will be educated on the elopement policy, location of binder, checking for placement of wander guard bracelets and the functionality of wander bracelets and educated to not place any residents on the far end of the unit. 4. All exit doors were now equipped with wander guard alarms and there was also a tag ID display which can identify which wander guard is trying to get through the door. 5. A keypad was installed at the entrance to the kitchen,so staff must enter a code to get in the kitchen. 6. Audits were initiated on all exit doors. Checklists for maintenance and the MOD (Manager on Duty) were initiated. 7. The facility held an Ad Hoc QAPI meeting on 3/31/21. Daily audits for wander alarm placement by the DON for 4 weeks and Maintenance Director for functionality for 4 weeks. Daily audits on ensuring staff are entering/exiting through the front door.

Based on medical record review, the review of pertinent records from a local hospital and emergency services provider, interviews with current and former staff, and interview with residents' attending physician, it was determined that the facility failed to: 1.) Ensure the expressed wishes of Resident #1 were clearly communicated to emergency services personnel on [DATE], the day the resident became unresponsive and unable to communicate said wishes; and 2.) Ensure residents' expressed wishes for life sustaining treatment were obtained and documented in a manner that involved the resident or the resident's representative. This was evidence for 3 of 21 resident reviewed during the revisit survey (Residents #1, #3, and #14). The facility's action and lack of oversight placed all residents at risk of suffering injury if cardiopulmonary resuscitation (CPR) was initiated against resident wishes. On [DATE] at 3:05 PM a determination of Immediate Jeopardy (IJ) was made regarding the facility's social worker taking steps on [DATE] to complete a new Medical Orders for Life-Sustaining Treatment (MOLST) form without the input from the residents or the resident's attending physician. These changes were different from the resident's previous MOLST form. The facility submitted three (3) plans of removal, the first on [DATE] at 4:25 PM which was not accepted, the second plan submitted on [DATE] at 6:05 PM which was not accepted, and the last plan was submitted on [DATE] at 7:27 PM. On [DATE] at 8:02 PM the facility's third removal plan was accepted by the Office of Health Care Quality. On [DATE] at 8:02 PM, after validation of the implementation of the acceptable removal plan, the Administrator was informed the IJ was removed. After removal of the immediacy, the deficient practice remained with the potential for more than minimal harm for all remaining residents at a scope and severity of D. The findings include: The Medical Orders for Life-Sustaining Treatment (MOLST) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments or do-not-resuscitate order (DNR). A DNR, is a medical order written by a doctor in collaboration with the resident or Health Care Agent and it instructs health care providers to initiate or withhold cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. The orders on a MOLST form are based on a patient's wishes about medical treatments. Instructions for completing a Maryland MOLST include: A Physician, Nurse Practitioner (NP), or a Physician Assistant (PA) must be accurately and legibly completing the form and then sign and date the MOLST. 1. On [DATE] a review of Resident #1's medical record revealed that on [DATE] the resident was transferred to the facility from a hospital. The resident arrived at the facility with a MOLST form dated [DATE]. The MOLST form indicated Resident #1 had orders for DNR/DNI (do-not-resuscitate/ do not intubate) with Supportive/Palliative Care and transferred to hospital for severe symptoms that cannot be controlled otherwise. A continued review of Resident #1's medical record revealed that on [DATE] at 1:14 PM Resident #1 was assessed by a nurse, Staff #7, after lunch. The resident was determined to be in respiratory distress. Staff #7 notified Resident #1's physician of the change in the resident's condition, and the decision was made to send Resident #1 to the hospital by emergency transport. On [DATE] a review of the Emergency Services Paramedic's (Paramedic #31) report concerning Resident #1's transfer from the facility to the hospital revealed that on [DATE] the paramedic received a digital copy of a MOLST form from the facility staff for Resident #1 that was electronically signed by a hospital physician. The MOLST form was dated [DATE] and indicated the resident had orders for DNR/DNI. The Paramedic then documented that a person in a lab coat, but no identification, handed her a second MOLST form for Resident #1. This form was dated [DATE] and signed by Physician #27. The MOLST form stated that the resident had orders for cardiopulmonary resuscitation (CPR), meaning the resident wanted CPR performed in the event of [CONDITION(S)]. On [DATE] at 10:00 AM an interview with the Administrator revealed Resident #1's MOLST form dated [DATE] was not scanned into the resident's electronic medical record at the time the resident was transferred to the hospital on [DATE], the document was located, in a pile of papers to be scan into the electronic medical record. A copy of the [DATE] MOLST form was given to the surveyor. On [DATE] a review of Resident #1's MOLST form dated [DATE] revealed the document was signed by Resident #1's facility attending physician (Physician #27) and indicated Resident #1 now wanted to cardiopulmonary resuscitation (CPR) and wanted all life sustaining procedures to be performed. There was no documentation in the resident's record to indicate that the resident or the resident's representative contributed or were asked about an existing MOLST. There was no documentation in the resident's record to indicate that the facility's staff asked the resident or the resident's representative about the resident's wishes for life sustaining treatment on [DATE]. On [DATE] at 10:30 AM in an interview was completed with Emergency Medical Services (EMS) Captain, (Captain #32) he acknowledged being aware of the incident with the facility providing EMS with multiple MOLST forms for Resident #1. He stated, that Paramedic #31 had informed him of such via email. On [DATE] at 11:14 AM an interview with Resident #1's physician (Physician #27) revealed the physician denied assessing Resident #1 on [DATE]. The physician further denied, being familiar with Resident #1. Physician #27 denied creating a new MOLST form on [DATE] for Resident #1. On [DATE] a review of the COVID-19 screening tool, a screening requirement for all entrants into the building, confirmed that Physician #27 did not enter the facility on [DATE]. On [DATE] at 11:49 AM Registered Nurse (RN) #17 was interviewed about the facility's process for confirming a resident's code status for new admission and readmitted residents during the weekends. RN #17 explained that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #17 further stated that the facility policy is to make residents that arrive at the facility without a MOLST form a full code (meaning initiate CPR in the event of [CONDITION(S)]), until verified by the physician. RN #17 further stated that on [DATE] Resident #1 was to have CPR performed. He added that he pulled the MOLST form from the code binder in the facility and gave it to Paramedic #22. When RN #17 was questioned if a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When questioned about Resident #1 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #17 then stated that he did not remember the code status for Resident #1 or if a MOLST form was in the resident's transfer packet from the hospital when the resident was admitted to the facility on [DATE]. On [DATE] at 8:15 am the Administrator revealed that the facility initiated an investigation into why and how the MOLST form on [DATE] was initiated. The Administrator further stated that Social Worker #23 was no longer employed by the facility, and Physician #27 was suspended until the completion of the investigation. On [DATE] a review of Resident #1's medical record from the transferring hospital, dated [DATE] revealed the emergency room (ER) physician reported that Resident #1 was unresponsive and not breathing when the resident was evaluated in the emergency room and the code documents were unclear as there was both full code and DNR/DNI on two separate pieces of paper that the ER physician received from the paramedic. The physician then called the resident's son before intubation to confirm the resident's code status and the resident's son confirmed the DNR/DNI code status. Resident #1 died on [DATE]. On [DATE], a review of the facility's MOLST policy and procedure, dated [DATE], revealed that every resident and/or family member would be asked by staff if they have a current MOLST form at the time of admission. If they have a MOLST form or one is provided to the facility from the hospital, a copy will be obtained, placed in the medical record, and the physician would be notified of the resident's MOLST form and orders would be written. Also, the physician would review the MOLST form with the resident and/or family and write corresponding orders. On [DATE] at 2:53 PM, an interview with the facility's former social worker, Social Worker #23, revealed that she was instructed in [DATE] to complete a full code (meaning initiate CPR in the event of [CONDITION(S)]) MOLST form for any resident that was not admitted with a MOLST form and that MOLST form should indicate the newly admitted resident should have orders to be full code (meaning initiate CPR in the event of [CONDITION(S)]). The Social Worker #23 stated that she completed a new full code MOLST form for Resident #1 on [DATE] because, I looked in the Code Binder and no MOLST form was in the code binder for the resident, and none was in the electronic medical record. The facility Social Worker #23 stated that she did not speak to the resident or Resident #1's attending physician on [DATE] before creating the new MOLST form. The Social Worker #23 stated that she used a pre-signed MOLST form she kept in the social work office for Physician #27. On [DATE] at 10:00 AM an interview with the Staff #8, the admitting nurse on [DATE]. Staff #8 recalled receiving a transfer packet for Resident #1 and confirming the orders with the on-call physician but does not remember if Resident #1 was a to have CPR or DNR/DNI orders upon admission to the facility. 2A. A review of Resident #3's medical record on [DATE] revealed Resident #3 was admitted to the facility on [DATE]. Further review revealed a MOLST form, dated [DATE], that indicated Resident #3's physician, Physician #27, completed and signed Resident #3's MOLST form on [DATE]. There was no documentation in the resident's record to indicate that the resident or the resident's representative contributed were asked about an existing MOLST. There was no documentation in the resident's record to indicate that the facility's staff asked the resident or the resident's representative about the resident's wishes for life sustaining treatment on or about [DATE]. On [DATE] at 9:06 a.m. in an interview, Physician #27 recalled signing a packet of blank forms during his onboarding process with the facility. The packet included order forms for medical supplies and medical necessity forms. Physician #27 did not recall if there was a blank MOLST form(s) included in the packet of blank documents. In an interview with Physician #27, on [DATE] at 3:38 PM, the physician denied visiting or evaluating Resident #3 on [DATE]. Physician #27 further denied completing or signing a MOLST form for Resident #3 on [DATE]. Physician #27 stated that he/she does not normally work on Saturdays and [DATE] was a Saturday. In an interview with Resident #3's responsible party on [DATE] at 3:14 PM, Resident #3's responsible party denied speaking to Resident #3 physician during Resident #3's admission to the facility. Resident #3's responsible party stated that he/she only spoke to the facility's Admission Director, Staff #22. Resident #3's representative further denied that the facility inquired about the resident's wishes for life sustaining treatment. 2B. A review of Resident #14's medical record on [DATE] revealed that Resident #14 was admitted to the facility on [DATE]. Further review revealed a MOLST form, dated [DATE], that indicated Resident #14's physician, Physician #27, completed and signed Resident #14's MOLST form on [DATE].There was no documentation in the resident's record to indicate that the facility's staff asked the resident or the resident's representative about the resident's wishes for life sustaining treatment on or about [DATE]. On [DATE] at 9:06 a.m. in an interview, Physician #27 recalled that he signed a packet of blank forms during his onboarding process with the facility. The packet included order forms for medical supplies and medical necessity forms. Physician #27 did not recall if there was a blank MOLST form(s) included in the packet of blank documents. In an interview with Physician #27, on [DATE] at 3:38 PM, the physician denied visiting or evaluating Resident #14 on [DATE] and denied completing or signing a MOLST form for Resident #14 on [DATE]. Physician #27 stated that he/she does not normally work on Saturdays and [DATE] was a Saturday. There was no documentation in the resident's record to indicate that the resident or the resident's representative contributed or were asked about an existing MOLST. Because of these findings, an Immediate Jeopardy was called on [DATE] at 3:05 PM was made regarding the facility social worker taking steps on [DATE] to complete 3 new MOLST forms without the input from the resident or the resident's attending physician. These changes were different in one of three resident's previous MOLST forms. A final removal plan was submitted on [DATE] at 7:27 PM and accepted at 8:02 PM. The Immediate Jeopardy was removed on [DATE] at 8:02 PM, after validation of the implementation of the acceptable removal plan, the Administrator was informed the IJ was removed. The facility's removal plan included the following provisions: 1. The facility Social Worker #23 is no longer employed by the facility. The attending Physician #27 has not practiced in the facility since [DATE]st, 2021. 2. All residents have the potential to be affected by this deficient practice. 3. A facility wide audit of all MOLST's was conducted by the Medical Director, Facility Corporate Nurse, Director of Nursing, and the Chief Nursing Officer on [DATE], [DATE], [DATE], [DATE] and [DATE]. All MOLST's for current residents were verified with the residents or the resident's responsible party. All MOLST forms were verified by the Medical Director, Attending Physician and Nurse Practitioner with the matching order in the Electronic Health Record. The Medical Director, Attending Physician and the Nurse Practitioner were educated on reviewing the orders from the hospital and signing MOLST form after discussion with a resident or contacting the resident's responsible party by the Chief Nursing Officer. The Medical Director, Attending Physician and the Nurse Practitioner were educated on not signing blank forms without documenting the resident's medical decision. The Corporate Social Worker was educated on not signing a provider's name on a blank MOLST form by the facility Corporate Nurse. The Admissions Director was educated by the facility's Corporate Nurse on assuring the referring hospital provides the facility with a completed MOLST. All licensed Nursing Staff will be educated by the Director of Nursing on the process regarding obtaining an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Any staff that did not receive education by [DATE]th, 2021, will be removed from the schedule until education is completed. Licensed Nursing Staff that were not in the facility was contacted by phone to receive education. The facility will update the MOLST policy on [DATE]th, 2021, outlining steps to be taken to obtain a provider's order for code status when a MOLST is not sent from the referring hospital. Licensed Nursing Staff, Licensed nursing staff, Licensed Social Worker, Medical Director, Attending Physician, Nurse Practitioner and Admissions Director will be educated by [DATE]th, 2021. 4. A daily audit of all MOLST forms with matching Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Thereafter, all MOLST forms will be reviewed daily in the facility morning meeting by the Director of Nursing. All audit results will be reviewed and discussed at the monthly Quality Assurance Performance Improvement Committee indefinitely. 5. Date of Compliance [DATE].

Based on medical record review and interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 5 of 25 residents reviewed in the complaint survey but affected all residents in the facility (Resident #12, #6 #9, #24, and #25). The findings include: 1) On [DATE] a review of Resident #12's medical record revealed the resident was discharged from the facility on [DATE]. On [DATE], eight (8) days after discharge a Coronavirus Pre-Assessment was completed on Resident #12 and recorded in the medical record. The assessment included Resident #12's temperature, taken on [DATE] at 7:36 AM, and recorded as 97.7 degrees. The inaccurate medical record assessment was confirmed with the Administrator on [DATE] at 1:11 PM. 2) A review of Resident #6's medical record on [DATE] at 1:18 PM revealed two Medical Orders for Life-Sustaining Treatment (MOLST) forms in the resident's record. The MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments or do-not-resuscitate order (DNR). A DNR order, is a medical order written by a doctor in collaboration with the resident or Health Care Agent and it instructs health care providers not to do cardiopulmonary resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops beating. The orders on a MOLST form are based on a patient's wishes about medical treatments. The first MOLST form came with Resident #6 from the hospital. The MOLST indicated the resident DNR with option A-2 (Comprehensive efforts may include limited ventilatory support by [CONDITION(S)] or [CONDITION(S)], but do not intubate). The back of the form had no check marks. The physician at the hospital signed his name electronically with on [DATE] at 9:30 PM. The MOLST was scanned into Resident #6's electronic medical record at the facility on [DATE]. The second MOLST form that was scanned in Resident #6's electronic record on [DATE]. This MOLST had, No CPR, option A-2 indicated, but had an X on page 2 for (4a), hospital transfer. The form had the same hospital physician's electronic signature and was dated [DATE] at 9:30 PM. The physician was not affiliated with the facility. There was no documentation as to why the back of the form was changed and it did not have a current physician's signature from the facility. The Director of Social Work was interviewed on [DATE] at 1:15 PM and could not explain how or why Resident #9's MOLST for was changed. The Director of Social Work stated she was not employed at the facility at that time when the resident was admitted . The Nursing Home Administrator (NHA) stated on [DATE] at 12:40 PM that she could not explain why the second page of the MOLST was altered without an up to date physician signature. 3) A review of Resident #6's medical record on [DATE] at 1:18 PM revealed a PASSR (Department of Health and Mental Hygiene Preadmission screening and Resident Review (PASRR) Level 1 ID Screen for Mental Illness and Intellectual Disability or Related Conditions Form). The form is a 2-sided form, however only 1 page of the form was scanned into Resident #6's electronic medical record. An interview with the Director of Social Work on [DATE] at 9:06 AM revealed the form should be front and back and if it is only one side that is in the medical record, it is wrong. The NHA was informed on [DATE] at 12:25 PM. 4) A review of Resident #9's medical record on [DATE] at 8:30 AM revealed documentation from Resident #24's physician's visit, dated [DATE], had been scanned into Resident #9's electronic medical record under the miscellaneous section. The NHA was informed on [DATE] at 12:45 PM. 5) A review of Resident #9's medical record revealed the facility failed to include one to one hourly monitoring sheets that were signed by nursing staff. The sheets were located throughout the Unit 2 nursing station, but were not maintained as part of the permanent record. The NHA brought the monitoring sheets to the surveyor on [DATE] at 12:15 PM. 6) A review of Resident #25's medical record on [DATE] at 11:00 AM revealed a MOLST form that had the bottom of the form cut off, therefore the physician's license number, phone number and date and time the form was signed was unknown. The MOLST was shown to the NHA on [DATE] at 12:25 PM. The facility did not have any original paperwork that came with residents on admission to the facility. On [DATE] at 1:01 PM an interview with Receptionist #7 revealed that she would scan medical records and give back to nursing or social work or she would shred. On [DATE] at 11:50 AM the NHA confirmed that there was no written process or checks and balances to make sure that all information was correctly scanned into the electronic medical record. 7) On [DATE] at 10:58 AM, a review Resident #2's medical record revealed a nurse's note, dated [DATE], which stated, resident left to go to the hospital The note did not reveal information about the method of transportation. During an interview conducted on [DATE] at 12:02 pm, Staff #18 stated that when a resident is sent out to the emergency room at the physician's request. The resident is sent with a transfer packet, a bed hold is placed, and the resident is transported either by 911 or private ambulance. Change of condition and transportation method are noted in PCC when a resident is sent to the emergency room . During the interview on [DATE] at 12:47 pm, Staff# 1 stated that Resident# 2's medical record in PCC had limited information regarding resident's transfer to hospital. 8) On [DATE] at 10:02 am, during a review of the medical record in the facility's electronic health record (EHR) system, Point Click Care (PCC), the surveyor was unable to locate Resident #3's admission agreement. During the interview conducted on [DATE] at 12:39 pm with Staff #17, the employee advised the surveyor that he/she was unable to locate a signed admission agreement for Resident # 3. Staff #17 confirmed the agreement was not scanned into the facility's electronic health record (EHR) system, Point Click Care (PCC). Staff #17 further stated he/she was unable to locate the admission agreement for Resident #3 in the binder which was the, Only other place the agreement would have been stored prior to the present admission process in PCC.

Based on review of medical records and other pertinent documentation and staff interviews, it was determined that the facility failed to conduct oversight of their social worker regarding the use of presigned Medical Orders for Life-Sustaining Treatment (MOLST) forms. This failure allowed the facility's social worker to complete presigned MOLST forms without speaking with the resident, the resident's family, or the resident's physician regarding end of life wishes. This was evidence for 3 of 21 resident reviewed during the revisit survey (Residents #1, #3, and #14). The facility's action and lack of oversight placed residents at risk of suffering injury if cardiopulmonary resuscitation (CPR) was initiated by following Physician #27 and Social Worker #23 MOLST orders. These failures placed all residents at risk for the facility staff not following each residents' wishes regarding end-of-life care. The findings include: A review of Resident #1's closed medical record on [DATE] revealed Resident #1 was admitted to the facility late in the evening on [DATE]. Resident #1 had a change in condition on Sunday [DATE] at approximately 1:30 PM. The decision was made to send Resident #1 to the local emergency room by 911 ambulance. A review of Resident #1's MOLST form, dated [DATE], indicated Resident #1 was to be a full code and wished to have all types of life sustaining care provided by the facility staff including [CONDITION(S)], intubation, and artificial nutrition and hydration. Resident #1's [DATE] dated MOLST form indicated that it was completed by Resident #1's physician #27, on [DATE]. In an interview with the facility's former social worker #23, on [DATE] at 3:16 PM, social worker #23 stated that he/she completed Resident #1's [DATE] MOLST form without speaking to Resident #1, Resident #1's family member, or Resident #1's physician. Social worker #23 stated that using a physician presigned MOLST form had been his/her practice since he/she started working at the facility in [DATE]. Social worker #23 stated that he/she used a physician presigned MOLST form with both Physician #27 and the facility's former Medical Director, physician #28, signatures since October of 2020. In an interview with Resident #1's physician #27, on [DATE] at 9:06 AM, physician #27 stated that he/she never saw Resident #1 on [DATE] nor did he/she complete a MOLST form for Resident #1 on [DATE]. Physician #27 stated that he/she does not normally work on Saturdays and [DATE] was a Saturday. In an interview with the corporate social worker #30, on [DATE] at 4:33 PM, corporate social worker #30 stated he/she was now working in this facility due to the parting of social worker #23. corporate social worker #30 stated that he/she has never completed a MOLST form or ever instructed any social worker in the corporation to complete a resident's MOLST form. Corporate social worker #30 stated that after a resident is admitted to the facility, the facility social worker should review the resident's MOLST form and then notify the resident's physician if something else is required. Corporate social worker #30 stated this may happen the next day after the resident is admitted . Corporate social worker #30 stated he/she currently has access to the facility social work office but was currently working out of the facility dining room. In an interview with the the facility's former Medical Director, physician #28, on [DATE] at 3:43 PM, physician #28 stated that he/she was not aware of the facility social worker #23, practice of using a physician presigned MOLST form, with his/her signature, to complete a newly admitted resident's MOLST form. Physician #28 stated he/she was not aware of signing any blank MOLST forms in the past. In an interview with the Administrator on [DATE] at 2:51 PM, he/she stated that the facility's Administrator and the Corporate Social Worker #30 were in charge of overseeing the facility's social worker. The Administrator also stated that he/she was not aware that the former social worker #23, had been storing 60 completed MOLST forms in the facility's social work office. Cross reference F 578

Based on observation, staff interviews, and review of medical records and other pertinent documentation, it was determined that the facility failed to implement adequate safety interventions to address the needs of residents assessed as having an elopement risk as evidenced by failure to provide adequate staffing to provide supervision to prevent an elopement of a resident with known exit seeking behaviors. This was evident for 1 of 5 residents (Resident #5) reviewed for wandering and risk of elopement. The facility also failed to document and report an elopement, investigate possible causes and means of the elopement after the fact which had the potential to affect all residents with an assessed elopement risk, ensure the Wanderguard system was checked for functionality on a weekly basis as indicated in the policy, and ensure that all of the exits were secured thus putting all residents with potential for elopement at increased risk. Due to this failure, on 9/13/17 at 7:30 PM an Immediate Jeopardy was called by the Office of Health Care Quality. An initial plan of action was given to the survey team for review on 9/13/17 at 8:30 PM and rejected. The 2nd plan of action was given to the survey team and the Office of Health Care Quality for review at 9:20 PM. The immediate jeopardy was removed at 9:30 PM after acceptance by the survey team and the Office of Health Care Quality. After removal of the immediacy, the deficient practice continued with a scope and severity of D with potential for than minimal harm for the remaining residents. The findings include: Review of MD 617 revealed an allegation of a resident elopement in August 2017. Per the facility Elopement Prevention/Intervention policy (revised 3/1/16) an elopement is defined as: When a resident who is cognitively, physically, mentally, emotionally or chemically impaired wanders away, walks away, runs away, escapes, or otherwise leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to scheduled discharge. On 9/8/17 review of the Elopement Prevention/Intervention Policy (revised 3/1/16) revealed: It is the policy of (name of company) to complete an Elopement Risk assessment for all new admissions, readmissions, quarterly, annually and with any significant change and implement interventions to prevent elopement .Equipment: Wander guard if elopement score is greater than 10 .Procedure: Wander Guard Checks: 1. The facility Director of Maintenance will check the Wanderguard System (all alarmed doors) weekly to ensure proper functioning; weekly checks will be documented in the Wanderguard System PM log. Staff will notify maintenance immediately of any malfunction in the system. Review of Resident #5's medical record revealed that the resident had resided at the facility for several years and had [DIAGNOSES REDACTED]. On 7/19/17 an Elopement Assessment was completed with an Elopement Risk score of 17. Scores of 10 or more indicate a resident is at risk for elopement. A Wanderguard was ordered and put in place and a care plan was initiated for risk of elopement. The Minimum Data Set assessment, dated 8/19/17, assessed the resident as having a BIMS score of 7 which indicates severe cognitive impairment and that the resident exhibited wandering behavior on 1 - 3 days during the 7 day assessment period. Review of the care plan approaches revealed: obtain psych consult as needed. On 8/17/17 the resident was seen by the psychologist. Review of this note revealed the following under Plan: Resident may no longer be suited for this setting. May need secured placement to prevent wandering. This psychologist note was dated 8/17/17 but was not entered into the electronic medical record until 9/7/17. Further review of the medical record failed to reveal any new interventions put in place after the 8/17/17 psychologist assessment. Further review of the care plan approaches revealed: Nurses: Assess/document and report to MD risk factors for potential elopement such as wandering, poor cognition due to dementia or Alzheimers; Nurses and Nurse Aide: redirect as needed. Review of the nursing notes for 8/19/17 revealed the following: *02:23 am Pain: no s/s of pain; *02:23: Mood Assessment from nurses: Resident sleeps regularly at night; *03:08: Behavior: cooperative; *03:09: Behavior: calm; *03:10: Behavior: calm; *07:21: Transfer to: ER/acute care hospital. (Name of Hospital) Time of transfer: 0711 AM DATE OF TRANSFER 8/19/17 TRANSFERRED FROM: other: (name of current facility) TRANSPORTATION: by ambulance REASON: for evaluation. PHYSICIAN NOTIFICATION: physician and or NP notified: (name of physician) Time 07:18 AM orders received: Send to ER for evaluation. RESPONSIBLE PARTY NOTIFICATION: RP notified Time: 7:20 AM Transfer packet provided to transporter. *10:21 AM Transfer packet provided to transporter. *01:00 PM vital signs were recorded for the resident. The medical record also revealed that on 8/24/17 a hand written note, dated 8/19/17 7-3 shift had been scanned into the electronic health record. Review of this hand written nursing note revealed the following: Resident is alert and responsive at the beginning of the shift. All due medications administered with no adverse reaction noted. Head to toe assessment done. Lung clear upon auscultation. Abdomen soft with bowel sound noted in all four quadrant. Resident tolerated Breakfast well. Denies pain on assessment. Resident remain stable and in no distress. On 9/7/17 at 2:00 PM after review of the above notes, the Director of Nursing (DON) reported that Resident #5 had not been sent to the hospital on [DATE]. The DON did not provide any explanation at this time as to why the transfer to ER note had been written. On 9/12/17 at approximately 9:15 AM review of the police report, dated 8/19/17, revealed the following: -At 5:43 AM Nurse #1 called the police and reported Resident #5 missing. -The responding officer arrived at the facility and spoke with Nurse #1 who reported that that the resident tries to leave the facility every night and went missing approximately one month ago. (name of resident) wears a sensor alarm on (his/her) wrist which is supposed to active when (s/he) gets close to an exit. The nurse stated that the sensor never activated. The nurse advised that (resident) attempted to leave at approximately 0200 hours and the sensor activated and did not leave. Sometime after that (s/he) left the facility and the nurse noticed (him/her) missing at approximately 0330 hours. -When the officer arrived at approximately 0543 hours, staff was completing a check of the building and had negative results locating the resident. -The officer obtained a picture of the resident and shared it with all working (name of jurisdiction) police officers and began to canvass the area. -While canvassing for the resident the communications office advised the officer that resident had been picked up and driven back to the facility. -The resident had been picked up and brought back to the facility by the ADON. -After resident was returned to the facility the granddaughter was present and stated that the resident has done this multiple times. -The ADON reported that she was in the process of having the resident moved to a Dementia Specialized facility in (name of town new facility located) and was awaiting acknowledgement of room availability. -The police Incident Detail report revealed that the incident was closed on 8/19/17 at 07:52. On 9/13/17 at 2:36 PM interview with the resident's responsible party confirmed that the resident had eloped from the facility in July but was unable to provide the specific date. Further review of the medical record revealed a note written on 8/23/17 by the Social Service worker which revealed the resident had been transferred to (name of new facility) on 8/19/17. There was no documentation in the resident's medical record by nursing staff or any other discipline on 8/19/17 to indicate that the resident was going to or had been transferred to another nursing facility on that date. On 9/8/17 at 9:55 AM surveyor requested from the Maintenance Director documentation of checks of the facility Wanderguard system from July 1 to present. The Maintenance Director was unable to provide evidence of weekly Wanderguard system checks. Documentation provided revealed that the most recent check of the doors had occurred on 8/22/17, but did not specifically address the Wanderguard system. On 9/8/17 at approximately 10:15 AM during an environmental tour with the Maintenance Director the Exit door adjacent to room #25 was able to be pushed open without entering the code to unlock the mag lock. The code pad light was noted to be red at the time, indicating the lock was locked, however the door opened. The Administrator was immediately informed and a check that all the residents were in the building was completed by staff. The Administrator reported that the Exit near room #25 was not supposed to be used by any staff for any purpose other than an emergency exit. Outside of the exit was a sidewalk leading to the sidewalk on the street. On 9/8/17 at approximately 10:30 AM during an environmental tour with the Maintenance Director the surveyor asked how he checks the Wanderguard system. The Maintenance Director reported that he does not check the Wanderguard system and he proceeded to ask the Administrator about the testing. The Administrator then obtained a Wanderguard from his office which was then used to test the Wanderguard alarm at the main entrance to the building. The Maintenance Director indicated that he had not previously been aware of this testing device. Surveyor reviewed the concern with the Maintenance Director that, according to the facility policy, the Director of Maintenance was supposed to check the Wanderguard system weekly. At 10:45 AM the Administrator reported that the door near room #25 would alarm if a resident with a Wanderguard was near the door, however when tested by the Administrator with the Wanderguard no alarm sounded. On 9/8/17 between 2:00 PM - 2:15 PM Surveyor #1 and #2, with the Administrator, checked the exit doors in the resident care areas. After the Administrator entered the code and pushed open the doors several times all of the doors latched shut with the mag lock engaging, except on one occasion. When the Exit door near room #25 was pushed open gently the mag lock failed to engage when the door swung shut. The Administrator reported that the codes had been changed that afternoon and that this was the first time the codes had been changed since he had become the Administrator. He went on to report that staff were not to use the door near room #25 unless there was an emergency. The Administrator went on to report that the only doors that the staff should be accessing are the front main entrance and the exit door near room #19. The exit near room #19 is used to access the dumpster and he stated that a different code would be put on this exit to allow staff to access the exit. Review of the facility floor plan revealed that there were 8 exits from the first floor to outside of the facility. One of the exits was only accessible thru the kitchen. The other 7 exits were in areas accessible by resident's who were ambulatory and were observed to have mag locks which required codes to be able to open the door. There was the main exit located in the lobby; and exits next to the following rooms: 53; 54; 19; 25; 37; and 40. Of note, the exit next to room 19, which opened to a parking lot and that staff were allowed to use when taking out the refuse, was not directly visible from the nurse's station. On 9/8/17 at approximately 4:00 PM when asked if he knew how the door near room #25 had become unlocked, the Administrator reported that he would be conducting interviews. The Administrator denied any knowledge of staff letting residents out of the building thru this exit door. On 9/12/17 at 2:30 PM the Assistant Director of Nursing (ADON) reported that the hand written nursing note dated 8/19/17 was hand written due to the resident having already been discharged from the facility and nurses are unable to chart on the computer after discharge. On 9/12/17 at 3:54 PM interview with Nurse #1, who was assigned to the resident on the night shift that ended at 7 AM on 8/19/17, revealed that on 8/19/17 around 5:00 AM the nurse was doing her rounds and discovered the resident was not in his/her room. According to the nurse they searched the building for the resident and couldn't find him/her. Nurse #1 then notified the police, the Director of Nursing (DON) and her manager. She went on to report that the resident had attempted to leave the facility earlier in the shift but the alarm had sounded. When asked when was the last time she saw the resident before the resident went missing the nurse stated, She stayed at the nursing station the whole time. The nurse also reported that the resident had been brought back to the facility by one of the managers. When asked if she documented anything about this incident the nurse responded, No ma'am, it was time for me to leave. On 9/13/17 at 11:15 AM interview with Nurse #2, who was also working the night shift that ended at 7 AM on 8/19/17, revealed that on 8/19/17 the resident left the building. Nurse #2 reported that Nurse #1 had informed him that she could not find the resident and that he proceeded to look outside. Nurse #2 was unable to locate the resident and instructed Nurse #1 to initiate a code yellow. Nurse #2 went on to confirm that Nurse #1 had informed him that the resident had attempted to leave earlier and that the Wanderguard had alarmed during the earlier attempt. When asked if any other providers use the locked doors to enter or exit the building, the nurse reported that the lab lady usually comes in and out through the side door. On 9/13/17 during an interview with the DON at 12:19 PM she reported that the only 2 doors that staff are suppose to use are the front door and the back door to the parking lot. On 9/13/17 at 11:40 AM the Administrator reported there were no incident reports for Resident #5 for July or August 2017. Review of the Elopement Prevention/Intervention Policy (revised 3/1/16) revealed: Procedure: UPON RETURN OF THE RESIDENT TO THE FACILITY: 8. Complete and forward an incident report to the Director of Nursing for review. On 9/13/17 at 11:42 AM the ADON reported that on 8/19/17 she was not scheduled to work but had been contacted and informed that the resident had left the building. Stating that since she lived near the facility she went to look for the resident, found the resident and brought the resident back to the facility. When asked what she expects the staff to do if a resident makes an attempt to leave the facility, the ADON responded: we do either 15 or 30 minute checks once we come to know. On 9/13/17 at approximately 12:00 PM the Administrator reported that there was no incident report because the resident had been safely brought back to the facility. He went on to report that he contacted (name of facility resident was transferred to) to see if they had any availability. On 9/13/17 at 2:36 PM interview with the resident's responsible party revealed that the facility had never given them an explanation as to how the resident eloped in August but that they (facility staff) had said the resident could have gotten out with the person that comes and does blood work. Review of the medical record failed to reveal any documentation from any discipline indicating or addressing the fact that the resident had eloped from the building on 8/19/17. On 9/13/17 at approximately 12 noon when asked if he had completed an investigation into the elopement the Administrator reported that he believed the DON had conducted the investigation. On 9/13/17 at 12:19 PM an interview was conducted with the DON in which the surveyor asked if there was any written documentation of interviews or checks conducted after the elopement. The DON reported that she had conducted verbal interviews but had not documented any of these interviews and was only able to recall having spoken with Nurse #1. On 9/13/17 at 12:45 PM surveyor requested any documentation regarding the investigation conducted after the elopement. The DON did provide a copy of hand written notes which she reported were from her personal notebook. Review of these notes, dated August 19, 2017, revealed: Interviewed staff: (blank space-no names listed) Results of interview: (name of resident) was noted to be in the building and nurse could not find (him/her). Found and noted to be safe. Further review of these notes from the DON's personal notebook revealed: Did education with staff on frequent checking on their residents. Did education on elopement prevention. On 9/13/17 at approximately 2:00 PM the DON provided a sheet of paper, dated August 19, 2017 with Elopement Prevention at the top of the page and a list of nine interventions which she reported was the education provided to staff post elopement, however she was unable to provide any documentation regarding which staff had been educated. The DON was also unable to provide any written statements from any of the staff on duty at the time of the elopement. On 9/13/17 at 9:13 PM surveyor asked the Administrator if an internal investigation had revealed that outside providers had access to the codes to the doors, what would he have done? His response was, 'change the codes.' Review of the most recent elopement assessments for the residents in the building on the night shift ending at 7:00 AM on 8/19/17 revealed that 16 out of the 92 residents (Residents #10, #8, #26, #27, #7, #11, #12, # 5, #13, #14, #15, #16, #17, #18, #19, #6) had been assessed as being at risk for elopement as evidenced by an elopement score of 10 or above. Of note, two of the residents assessed as having an elopement risk and still currently residing in the facility as of the start of the survey (9/6/17), were assigned to the two rooms directly adjacent to the exit door that was found to be unsecured on 9/8/17. The facility is all on one floor and all residents who are mobile have access to all of the hallways. On 9/13/17 twelve of these sixteen residents assessed as elopement risks were still residing at the facility. Further review of the elopement assessments for the residents currently in the facility revealed that Residents #20, #21, #22 and #23's most recent elopement assessment had been completed in January 2017, and Resident #24's last elopement assessment was in October 2016. On 9/13/17 when the surveyor asked about the investigation regarding the observed unlocked door on 9/8/17 the Administrator referred the surveyor to the DON. On 9/13/17 the DON provided documentation of staff attendance at in-services conducted on 9/9/17, 9/10/17 and 9/11/17 regarding Entrance and Exit doors. The DON also reported that all staff that signed the in-service sheets denied having accessed the door that had been found opened on Friday 9/8/17. On 9/13/17 during the 12:19 PM interview the DON reported that one of the residents said that the staff might have gone out the door to smoke or use the cell phone but in a follow up interview at 3:49 PM the DON was unable to recall which resident had told her this. No documentation was provided regarding any interviews or statements about the unsecured door. On 9/15/17 at 12:47 PM interview with Nurse #1 confirmed that she had spoken with the DON on 8/19/17 regarding the elopement of Resident #5 but that no written statement had been requested of her by the facility management on the day of the elopement, and that she had not yet provided any written statement regarding the elopement to the facility. On 9/15/17 during the 12:47 PM interview with Nurse #1, who reported that she had cared for Resident #5 prior to 8/19/17 and was familiar with the resident's needs, she confirmed that the resident tried to leave the facility every night stating, this is what the resident normally does. The nurse also reported that the resident kept saying s/he wanted to leave and that the resident's attempt to leave with the alarm being activated was not unusual. When asked about the administration's expectations when a resident attempts to leave the facility the nurse responded, that night there were just 3 nurses and 3 GNAs (geriatric nursing assistants) and we do our best to attend to everyone's needs. She went on to report that there was supposed to be 4 nurses plus a supervisor at night for a total of 5 nurses. When asked if she was aware of a plan to transfer the resident, Nurse #1 responded, no. During this interview Nurse #1 confirmed that the lab person usually used the exit near Room #40 where the vending machines were located. Review of staffing sheets and timecards confirmed that only 3 GNAs (GNA #20, #19 and #12) and 3 Nurses (Nurse #1, Nurse #2 and Nurse #7) were working on the 8/18/17 night shift. Review of the scheduling sheet for 8/18/17 revealed that 4 GNAs had been scheduled for the night shift but there was a hand written notation: r/o assignment changed by DON 8/18/17. Review of the staffing sheet revealed that all of the rooms that would have been assigned to the 4th GNA had been reassigned to the other three. On 9/20/17 at 10:34 AM interview with the Staffing Coordinator revealed she tries to schedule at least one supervisor, 4 GNAs and 4 nurses for the night shift but that there is currently no night supervisor, just a charge nurse at night. The staffing coordinator reported that 'r/o' stands for 'requested off' but that she had scheduled the GNA #17 to work that night. The staffing coordinator went on to report that someone, she believed it was GNA #19 (who was working that night shift) called to inform her GNA #17 was not there. She then reported that she notified the DON. On 9/20/17 at 11:49 AM interview with the Administrator confirmed that the facility had still not identified how Resident #5 had exited the facility on 8/19/17. He also reported that the DON had started obtaining statements from staff regarding the incident. During this interview surveyor requested any additional investigation/statements they had obtained regarding the elopement. On 9/20/17 at 5:00 PM the DON provided written statements from Nurse #1, GNA #20 and GNA #12. Nurse #1 statement was dated 9/16/17. GNA #20's statement was dated 9/15/17. GNA #12's statement referenced the 8/19/17 night shift but did not include a date as to when the statement was written. The DON reported that Nurse #7 no longer worked at the facility and that his phone number had been changed. The DON also reported she was still awaiting statements from two additional staff members. No documentation was found as to what, if any, questions had been asked of the staff regarding the elopement. The facility's failure to implement adequate safety interventions to address the needs of residents assessed as having an elopement risk and to ensure that elopements were investigated and reported to the state survey and certification agency, resulted in an Immediate Jeopardy to resident health and safety. This was identified on 9/13/17 at 7:30 PM by the Office of Health Care Quality. An initial plan of action was given to the survey team for review on 9/13/17 at 8:30 PM and rejected. The 2nd plan of action was given to the survey team and the Office of Health Care Quality for review at 9:20 PM. The plan to remove the immediacy included, but was not limited to: -All doors were checked to ensure functioning of the Wanderguard system and the mag locks. The master code for all doors is only known to the Administrator, DON, Maintenance Director, Corporate Governing Body and the Local Fire Department. All other staff will only have code access to the front door and back door leading to the dumpster. The staff code will be changed monthly for extra security. -All staff to be in-serviced prior to the start of their next shift on Elopement Policies and Procedures and monitoring of residents. -Any resident with an attempt of elopement will be re-assessed and put on 15 minute checks by staff that will be recorded in the medical record. -Any attempt of an elopement will be reported to the Administrator immediately. Administrator to follow facility policy on self-reporting and report the incident to the Office of Health Care Quality and the governing body. -Administrator will audit all new admissions and quarterly for all residents in house to ensure that elopement risks are done and appropriate interventions are in place. Results of the audit will be reported to the QA Committee for a period of 3 months. The immediate jeopardy was removed at 9:30 PM after acceptance by the survey team and the Office of Health Care Quality. Cross reference to F 514.