Every finding on record at Complete Care at Springbrook

Based on observations and interview it was determined that the facility staff failed to maintain a comfortable homelike environment for residents. This deficient practice was discovered in 6 resident rooms observed during the complaint survey.The findings include:1. On 08/07/26 at 11:05 am during observation rounds the surveyor observed the following: 1a. damaged drywall and trim on the left side of the entryway of room [ROOM NUMBER].1b. There was a hole in the wall in the bathroom near the commode in room [ROOM NUMBER].1c. The towel bar was broken in the shared bathroom of Rooms 120-122.1d. In room [ROOM NUMBER] there were two holes in the wall below the peg board near the foot of Bed A.2. On 08/11/26 at 1:47 pm while speaking with Resident #7 in room [ROOM NUMBER], the surveyor observed a hole in the wall near the call bell system. There was old drywall plaster around the hole. 3. On 08/11/26 at 2:01 pm while in room [ROOM NUMBER]-B the surveyor observed a sheet on the floor in front of the air conditioning unit. The surveyor touched the sheet, and it was soaked with water.On 08/12/26 at 8:22 am during an interview with Maintenance Director #4 the surveyor reported the maintenance concerns observed and asked if there was a preventative maintenance schedule. Maintenance Director #4 verbalized they have an assistant which helps with maintenance concerns. If there is a concern the staff will show them the concern or put the issue into TELS (electronic building management system). They deal with the issue right away and if necessary call an outside contractor. The surveyor asked if there were any maintenance requests for the observed concerns. Maintenance Director #4 verbalized not that they are aware. The Preventative Maintenance schedule is in TELS. Every morning they check the residents' rooms to be sure they are good. In room [ROOM NUMBER] the condensation from the AC unit caused water to be on the floor. They checked the unit for a leak. It was not reported to maintenance that the floor was wet. The surveyor made Maintenance Director #4 was aware Resident #10 reported water comes through the window when it rains.

Based on record review and interviews it was determined that the facility staff failed to complete a thorough investigation when investigating allegations of abuse or neglect. This deficient practice was evidenced in 4 (#5, #6, #7, #10) of 9 investigations reviewed during the complaint survey.The findings include: 1. On 08/07/26 at 2:37 pm a review of the facility's investigation related to Resident #5 allegation of neglect revealed the resident alleged GNA #13 failed to provide incontinence care to the resident. The staffing sheets when the alleged incidents occurred and the statements provided revealed a statement or interview from GNA #14 was not included in the investigation. GNA #14 worked on 06/14/26 during 3pm - 11 pm shift on the [NAME] Unit where the alleged incident occurred. 2. On 08/10/26 at 2:00 pm a review of the facility's investigation related to Resident #7 allegation of abuse revealed there was not a statement or interview from GNA #15 and GNA #16. During an interview with Interim DON #2 the surveyor asked why an interviews or statements from GNA #15 & GNA #16 were not included in the investigation. Interim DON #2 verbalized they did not have a reasonable explanation why they were not interviewed. On 08/10/26 at 2:24 pm the surveyor reviewed the Abuse, Neglect, and Exploitation policy with the Interim Director of Nursing (DON) #2 and asked them to explain their process of completing an investigation. Interim DON #2 reported they assess the situation, interview staff that were present on that assignment or the unit, and interview residents who are interviewable. They review the statements to determine if anybody heard or saw anything and they prefer to perform interviews vs statements. 3. On 08/11/26 at 4:12 pm a review of the investigation related to Resident #6 allegation of neglect revealed 32 staff were interviewed and according to the dates on the statements the interviews were not from staff who worked during the time of the alleged incident. During interview at 5:20 PM, Regional Clinical Consultant #6 reviewed the staff statements and confirmed there was not a statement from GNA #2, GNA #17, and GNA #18 who worked during the time of the alleged incident were not interviewed.4. On 08/13/23 at 11:00 am a review of the facility's investigation concerning Resident #10 allegation of abuse revealed the resident reported GNA#8 left them soiled on 08/05/26 during 3 pm - 11 pm shift until the next shift staff arrived. A review of the staffing sheet and incontinence documentation revealed that GNA #12 who documented they provided incontinence care on 08/05/26 during the 11 pm - 7 am shift was not interviewed. A statement from the GNA was not part of the facility's investigation.

Based on record review and interviews it was determined that the facility staff failed to assist a resident with incontinence care and failed to alert the oncoming staff that the resident needed incontinence care. This deficient practice was evidenced in 1 (#10) of 3 resident records reviewed for activities of daily living (ADL) care during the complaint survey. The findings include:Activities of daily living are basic routine tasks that most healthy individuals can perform without assistance. These activities include personal care tasks such as eating, dressing, bathing, toileting, managing continence, and transferring (moving from 1 position to another). The ability to perform activities of daily living is an essential measure of an individual's functional status. The inability to perform basic activities of daily living may lead to unsafe conditions and a poor quality of life. On 08/11/26 at 2:01 pm during an interview with Resident #10 the surveyor asked did they have an issue with getting assistance with getting changed after they had a bowel movement. Resident #10 verbalized they explained to GNA #8 they had a bowel movement about 10 pm and needed to be changed. GNA # 8 came back to the room around 10:35 pm. The surveyor asked when did the incident occur. Resident #10 verbalized it happened on 08/05/26 during 3 pm - 11 pm shift. The surveyor asked did GNA #8 change them. Resident #10 reported GNA #8 told them they got off in 10 minutes, and they would let the next shift know. The GNA who worked night shift changed them.On 08/12/26 at 11:55 am during a telephone interview with GNA #8 the surveyor asked did anything happen when they were assigned to Resident #10. GNA #8 verbalized on 08/05/26 Resident #10 put their call light on about 10:45--10:50 pm when they put Resident #10 roommate to bed. Resident #10 asked for 2 cups of ice and they emptied the urinal. Afterwards they checked on the other residents assigned to them. Afterwards they went back to Resident #10 room, and Resident #10 indicated they had a bowel movement. The surveyor asked GNA #8 if they changed the resident. GNA #8 verbalized it was time for them to go and changing the resident require 2-3 people. The resident weighed about 600 pounds. They went to ask GNA #10 for assistance, but they were busy with another resident. They asked another GNA for assistance, but they were doing their last rounds so the resident had to wait until the next shift as GNA #8 had an emergency and had to go home. GNA #11 was assigned to Resident #10 during the night shift and didn't show up until after 11 pm. They did not abandon the resident. The surveyor asked who was made aware the resident was soiled and needed assistance. GNA #8 verbalized they didn't tell anybody. The other GNA wasn't working in their area, and they didn't see the nurse and if they had GNA #11's phone number they would have called them.At 12:06 pm the during a telephone interview with GNA #10 the surveyor asked if GNA #8 asked for assistance with changing Resident #10 on 08/05/26. GNA #10 verbalized it was about 10:45 pm they were doing rounds. Close to 11 pm GNA #8 was looking for someone to assist them with changing Resident #10, but GNA #8 said GNA #10 was busy and they would find someone else. When they finished with the resident they didn't see GNA #8. GNA #10 verbalized they were not certain if GNA #8 was able to find assistance with changing the resident.On 08/13/26 at 11:11 am a review of Resident #10 electronic health record revealed GNA #12 documented they provided bowel incontinence care to the resident on 08/06/26 at 12:53 am. Resident #10 was soiled for over two hours.A review of Resident #10 MDS Section GG 0130 Self Care: Question C Toileting Hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement, Resident #10 was coded as being dependent for care.

Based on record review and interviews it was determined that the facility staff failed to document whether a resident received incontinence care. This deficient practice was evidenced in 1 (#7) of 3 medical records review for ADL care during the complaint survey.The findings include:On 08/11/26 at 1:30 pm a review of Resident #7 ADL care located in the Task section of the electronic health record (EHR) revealed on 8/02/26, 7 am - 3 pm, 8/05/26 7am - 3pm, 8/07/26 7am - 3pm, 8/08/26 7 am - 3 pm, 8/09/26 3 pm - 11 pm, and 8/10/26 7 am - 3 pm shift the Geriatric Nursing Assistant (GNA) assigned to the resident did not document whether the resident received bladder incontinence care. The GNA assigned to the resident on 8/05/26 7 am -3pm, 8/07/26 7 am - 3pm, 8/08/26 7 am - 3 pm, 8/09/26 3 pm - 11 pm, and 8/10/26 7 am - 3 pm did not document if the resident received bowel incontinence care.On 08/11/26 at 1:29 pm during an interview with Interim Director of Nursing (DON) #2 the surveyor asked who was responsible for ensuring the Geriatric Nursing Assistant's (GNA) complete their documentation. Interim DON #2 verbalized the nurse manager reviews the documentation during the day and the supervisor reviews the documentation in the evening.On 08/11/26 at 1:34 pm during an interview with RN Unit Manager #7 the surveyor asked when were the GNA's expected to document when they provide incontinence care and who is responsible for ensuring the documentation is completed. RN Unit Manager #7 verbalized the GNAs are expected to document in PCC (electronic health record system) during their shift and before they leave for the day. Normally they check to ensure the documentation is completed daily before they clock out of their shift. The surveyor asked why the documentation was not completed for Resident #7 and RN Unit Manager #7 verbalized they can't defend their actions.On 08/13/26 at 1:17 pm during an interview with GNA #15 the surveyor asked when a resident requires incontinence care, when were they expected to document in the electronic health record. (EHR). GNA #15 verbalized after they finish assisting the resident, they document what care is provided. If they are having a busy day, they document when they get a moment, but no specific timeframe. They can document once a shift and if the resident has another episode the nurse will be made aware.On 08/13/26 at 1:21 pm during an interview with GNA #19 the surveyor asked when they document in the EHR when a resident received incontinence care. GNA #19 verbalized after they have a bowel movement they document. If not, then they would document at the end of the shift. They are expected to document whether the resident required incontinence care or not.

Based on observation and interview, it was determined that the facility failed to ensure a safe, clean, and comfortable homelike environment for the residents. This was evident for multiple areas within the facility observed during the annual survey. The findings include: 1.On 04/27/2026 at 07:31 AM, an observation of the dining room revealed the wall across from the door to the basement stairs by the kitchen door, which had a hole in the wall that was approximately 4 inches long and 2 inches wide. On 04/27/2026 at 7:52 AM, an observation of the left bottom corner wall outside of room [ROOM NUMBER]-CD when looking into the room revealed a piece of the dry wall which was missing, a portion of the wall that exposed through a cracked, and the footboard which was detached from the wall at the end. On 04/27/2026 at 7:53 AM, an observation of the hallway wall outside of room [ROOM NUMBER] which had a large horizontal hole in the wall which was approximately 36 inches long and 2 inches wide. On 04/27/2026 at 7:58 AM, an observation of room [ROOM NUMBER] revealed the outside of the bathroom door has a horizontal indent that was approximately 6 inches long and an inch wide Further observation of room [ROOM NUMBER] revealed the wall to the right of the B bed when looking at the bed, which had an indent in the wall and exposed the inside of the wall. The indent as a whole was approximately 4 inches long and 12 inches wide. Further observation of room [ROOM NUMBER] revealed the foot board of the B bed was completely detached from the bed and was leaning on the steel frame of the bed. On 04/27/2026 at 8:06 AM, an observation of room [ROOM NUMBER] revealed 3 separate areas of the window blinds which were broken off. On 04/27/2026 at 9:19 AM, an observation of room [ROOM NUMBER] revealed the television wall mount had been moved from where it previously was on the wall, which exposed 5 various sizes of holes in the wall from approximately 2 centimeters by 2 centimeters to approximately 2 inches by 2 inches. One of the holes on the wall had a black wire coming out of it connecting to where the new television mount was. On 04/27/2026 at 11:15 AM, an observation on room [ROOM NUMBER] revealed the heating, ventilation, and air conditioning unit (HVAC) which had a square size area about 5 inches by 5 inches, without a cover, leaving the inside parts of the unit exposed. On 04/27/2026 at 11:39 AM, an observation of the unit hallways revealed room [ROOM NUMBER], 116, 119, and 121 had a room number plaque which the room numbers were written in with sharpie and/or cracked. On 04/27/2026 at 11:56 AM, an observation of room [ROOM NUMBER] revealed a nightstand dresser across from the A bed which was missing the drawer. Further observation of room [ROOM NUMBER] revealed the call bell wall outlet, which failed to have an electrical outlet cover on it. On 04/29/2026 at 8:59 AM, an interview with the Maintenance Director (Staff #22) revealed that he was informed of maintenance concerns through an online system. He further said the facility was in the process of fixing a lot of maintenance concerns since he started in March 2026. On 04/29/2026 at 9:13 AM, the surveyor walked around with Staff #22 to review the identified concerns noted above. The surveyor reviewed the concern. 2. On 4/27/26 at 9:13 AM during the initial rounds on the floor, the surveyor observed in room [ROOM NUMBER]- a hole in the wall behind the entrance door measuring about 5x6 inches, it looked like it was punched in. In room [ROOM NUMBER] bathroom, the toilet seat was scrapped off in three different spots exposing the brown wood underneath and around the edges measuring about 7 x 0.5 inches, 3 x 2 inches and 4 x 0.25 inches respectively. On 4/27/26 at 9:33 AM in room [ROOM NUMBER]B, Resident #88's nightstand was observed missing on the front, a brown piece of wood in the 2nd drawer from the top. At the foot of the bed, the corner of the baseboard was broken off, and a large white spot was also visible at the base of the wall. The resident's bed was up against the wall and the white paint by the window ceil next to the bed was chipped off about 12 inches long exposing the wood. The surveyor also observed on 4/27/2026 at 11:06 AM in room [ROOM NUMBER]B, that Resident #54 had a wheelchair by their bed. The Wheelchair seat was torn exposing white particles underneath including the arm rest and back rest area measuring about 4x16 inches. Resident #54 also stated that the phone on their nightstand can't receive calls but can dial out. The surveyor further observed that the foot board on Resident #54's bed was ripped off about 7x4 inches exposing the sharp edges. In an Interview with the maintenance director #22 on 4/29/2026 at 8:55 AM, he was asked how often he rounds on the units, and he said daily but have a weekly and monthly scheduled checks. He explained that the staff use a system called TELS to place work orders for him on the units or to notify him of what needs to be fixed. He was asked if he does regular room checks and he said they don't but have a section-by-section plan room checks. The maintenance director was made aware that some of the residents' beds are in terrible condition, and he said some of the beds are old and mechanical and he is in the process of checking and removing all the old equipment, repainting rooms, and touching up on the buildings. On 4/29/2026 at 9:25 AM The surveyor did a walk around with the maintenance director and the administrator. The surveyor made them visually aware of all the environmental concerns; they agreed that it was a concern and said they would take care of it.

Based on medical record review and staff interview, it was determined the facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days after the assessment reference date. This was evident for 6 (Resident #22, # 41, #80, #47, #58, and #69 ) of 7 residents reviewed during the annual survey. The findings include: 1, The Minimum Data Set (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 these individualized needs, and that the care is provided as planned to meet the needs of each resident. The MDS is to be completed 14 days after the assessment reference date (ARD). On 4/28/2026 at 9:35AM medical record review of the MDS assessment revealed that Resident #22 the MDS completion date of 4/13/2026 was late. Resident # 41 the MDS completion date of 4/13/2026 was late. Resident #80 the MDS completion date of 4/13/2026 was late. 04/30/2026 8:27 AM Staff #18, the Regional Director of Reimbursement, MDS was Interviewed and confirmed the above quarterly assessments are overdue and were not completed timely. 2. On 04/29/2026 at 10:35 AM, review of Resident #47's medical record revealed the MDS completed on 4/13/2026 was late (more than 14 days after the ARD of 3/26/2026). On 04/29/2026 at 10:37 AM, review of Resident #58's medical record revealed the MDS completed date on 4/13/26 was late (more than 14 days after the ARD of 3/21/2026). On 04/29/2026 at 10:46 AM, review of Resident #69's medical record revealed the MDS completed on 4/14/26 was late (more than 14 days after the ARD of 3/29/2026). On 04/30/2026 at 8:27 AM, an interview with the Regional Director for Reimbursement confirmed the findings noted above that the MDS assessments were completed late. On 05/01/2026 at 1:23 PM, the surveyor reviewed the concern with the Nursing Home Administrator during the survey exit conference.

Based on review of Minimum Data Set (MDS) Assessment material and interview with facility staff, it was determined that the facility failed to transmit MDS assessments within 14 days of completion of the assessment. This was evident for 5 (Resident #22, #41, #80, #47 and #58 ) of 7 residents reviewed during the annual survey. The findings include: 1.On 4/28/2026 at 12:05 PM information from the Centers for Medicare and Medicaid (CMS) regarding transmission of Minimum Data Set (MDS) Assessments were reviewed. The review revealed that the MDS was not transmitted timely. Resident #22 The assessment Assessment Reference Date (ARD) 4/13/26 was transmitted to CMS late. Resident #41 The assessment ARD 3/20/26 was transmitted to CMS late. Resident #80 The assessment ARD 4/13/26 was transmitted to CMS late. 04/30/2026 8:30 AM Staff #18, the Regional Director of Reimbursement, MDS was Interviewed and confirmed the above MDS assessments were overdue and were not transmitted timely. 2. On 04/29/2026 at 10:35 AM, review of Resident #47's medical record revealed the MDS completed on 4/13/2026 was transmitted late (more than 14 days after the completion date of 4/13/2026). On 04/29/2026 at 10:37 AM, review of Resident #58's medical record revealed the MDS completed on 4/13/26 was transmitted late (more than 14 days after the completion date of 4/13/2026). On 04/30/2026 at 8:03 AM, review of the MDS Final Validation Report which shows when the MDS was transmitted confirmed that Resident #47 and #58's recent MDS assessments noted above were transmitted late. On 04/30/2026 at 8:27 AM, an interview with the Regional Director for Reimbursement confirmed the findings noted above that the MDS assessments were transmitted late. On 05/01/2026 at 1:23 PM, the surveyor reviewed the concern with the Nursing Home Administrator during the survey exit conference.

Based on observations, Resident and staff interviews and surveyor record reviews it was determined that the facility failed to code Minimum Data Set (MDS) Assessments accurately for Residents. This finding was found to be evident in 2 (Resident #13 and #23) out of 2 Residents reviewed for falls and continence. The findings include:The Minimum Data Set (MDS) is a federally mandated, standardized clinical assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a Resident's functional, medical, psychosocial, and cognitive status, including skin and health conditions, nutrition, continence, medications, treatments, and active diagnoses. It drives care planning, quality monitoring, and reimbursement, with assessments required upon admission, quarterly, annually, discharge and significant changes in status of Residents. The assessment is completed by licensed health care professionals employed by the nursing home, such as a Registered Nurse (RN). The information is transmitted electronically to the Centers of Medicare and Medicaid Services (CMS). The purpose of the MDS is to ensure accurate, comprehensive assessments to improve Resident care and identify health problems. The data helps form the basis for individual Resident care plans. A Care Plan is a formalized, dynamic document outlining a Resident's health conditions, goals, and specific interventions, created collaboratively by healthcare professionals, patients, and families. The care plan ensures personalized care, tracks progress, and includes medication, treatment plans, and provider information to improve health outcomes and safety, especially for chronic conditions. The key components of a care plan include assessment (identification of Resident needs, symptoms, and medical history), nursing diagnosis (identification of specific patient health problems), goals/desired outcomes (actionable, measurable, and patient-centered targets), interventions (specific, planned actions to be taken by the interdisciplinary care team), and evaluation (regular review of the plan's effectiveness, adjusting as needed). The care plan streamlines care delivery and helps manage long-term needs.A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall, bringing a portion of the colon through to allow waste to pass into a pouch, typically for treating bowel cancers, obstructions, or injuries. The colostomy can be temporary or permanent and allows for a normal lifestyle.The surveyor observed Resident #23 on 4/29/2026 at 10:30 AM in bed, in no distress, alert and oriented to person. Resident stated that he/she was doing okay and that the colostomy bag was not leaking.The surveyor conducted a record review of Resident #23's medical record on 4/29/2026 at 1:15 PM. Record review revealed that Resident #23 had a physician order for colostomy care and a comprehensive care plan that addressed the Resident's colostomy care. Further review of the medical record revealed that the admission Medicare 5-Day MDS assessment dated [DATE] was coded that Resident #23 had a colostomy, however, bowel continence was coded always incontinent.At 3:35 PM on 4/29/2026 the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) were notified that Resident #23's admission Medicare 5-Day MDS assessment was coded inaccurately for bowel continence because the Resident had a colostomy, but the MDS assessment was coded always incontinent instead of Not rated. The LNHA and the DON acknowledged the surveyor and stated that they would follow up with the MDS Coordinator.In a follow up record review on 4/30/32026 at 7:10 AM of Resident #23's admission Medicare 5-Day MDS assessment dated [DATE], the review revealed that there was a correction/modification to the MDS on 4/29/2026 at 4:16 PM by the MDS Coordinator. Bowel continence was coded Not rated on the Modification of admission Medicare 5-Day MDS assessment.In an interview with the RN MDS Coordinator #18 on 4/30/2026 at 8:30 AM the surveyor asked what the expectation was for coding bowel continence for Residents with a colostomy on the MDS assessment. RN MDS Coordinator #18 stated that bowel continence should be coded Not rated on the MDS assessments when Residents had a colostomy. The surveyor conveyed that Resident #23 was coded for a colostomy on the admission Medicare 5-Day MDS assessment dated [DATE], however, bowel continence was coded as always incontinent. RN MDS Coordinator #18 stated that this was not accurate coding, and a modification/correction was made to the admission Medicare 5-Day MDS assessment that indicated bowel continence as Not rated.A record review was conducted by the surveyor on 4/30/2026 at 3:45 PM for Resident #13's medical record. Review of the medical record revealed that Resident #13 had a fall on 2/19/2026 with left thigh pain and sustained a fracture of the left femur as indicated on the Resident's hospital discharge summary. Further review of the discharge summary revealed that the Resident had surgical repair of the left femur fracture, intramedullary nailing and fixation of the left femur fracture. Review of the Discharge MDS assessment dated [DATE] was coded that Resident had 2 or more falls without injury. Additionally, review of the Quarterly MDS assessment dated [DATE] revealed that the orthopedic surgery (intramedullary nailing and fixation) for repair of the left femur fracture was not coded on the MDS.In an interview with the RN MDS Coordinator #18 at 8:45 AM on 5/1/2026 the surveyor asked what the expectation was for coding MDS assessments for a fall with a fracture and a surgical procedure. RN MDS Coordinator #18 stated that the MDS assessment should be coded as a fall with major injury if a Resident falls and sustained a fracture and the surgical procedure should be coded on the MDS assessment if the surgical procedure occurred within 30 days. The surveyor conveyed that Resident #13 had a fall with fracture on 2/19/2026 and a surgical procedure to repair the fracture on 2/20/2026, and the Discharge MDS dated [DATE] was not coded for the fall with fracture, and the Quarterly MDS dated [DATE] was not coded for the surgical procedure. The RN MDS Coordinator #18 acknowledged the surveyor and stated that she would make the necessary corrections / modifications to these MDS assessments. Follow up record review at 12:15 PM 5/1/2026 of Resident #13's MDS assessments revealed that the Modification of 2/19/2026 Discharge MDS was coded for a fall with major injury (fracture), and the Modification of 3/16/2026 Quarterly MDS was coded for the surgical procedure (repair fracture of leg).Nephrostomy tube is a thin, flexible catheter inserted through the skin of the back into the kidney to drain urine directly into an external bag, bypassing blockages caused by tumors, stones, or infections. This ultrasound-guided procedure that takes approximately 30-90 is usually temporary but requires daily care (cleaning and flushing) and brings risks of infection or blockage, often every three months.Further record review on 5/1/2026 of Resident #13's Quarterly MDS assessment dated [DATE] revealed that it was coded that Resident had an indwelling catheter (nephrostomy tube), however, Resident did not have an indwelling catheter (nephrostomy tube) at that time because the indwelling catheter (nephrostomy tube) was removed on 2/4/2026. This removal of the nephrostomy tube was documented at 22:39 on 2/4/2026 in a nurse's progress note.In a follow up interview with the RN MDS Coordinator #18 on 5/1/2026 at 11:20 AM the surveyor conveyed that Resident #13's Quarterly MDS dated [DATE] was coded that Resident had an indwelling catheter (nephrostomy tube), however, the indwelling catheter (nephrostomy tube) was removed on 2/4/2026. RN MDS Coordinator #18 stated that she would review the notes as she was not sure of the status of the nephrostomy tube. The Director of Nursing (DON) was notified of the concerns with the inaccurate coding on the MDS assessments for Resident #13 at 11:30 AM on 5/1/2026.In an interview with the RN Unit Manager #21 at 11:45 AM on 5/1/2026 she stated that Resident #13 had a nephrotomy tube for a short time period, but it was removed. RN Unit Manager #21 provided the surveyor with progress notes from Resident #13's medical record, one progress note dated 12/4/2025 which indicated that the nephrostomy tube was inserted and the other progress note dated 2/4/2026 which indicated that the nephrostomy tube was removed. RN Unit Manager #21 confirmed that Resident #13's nephrostomy tube was removed on 2/4/2026.No additional information was provided by the facility at the time of survey exit.

Based on observation and interview, it was determined that the facility failed to ensure residents were served meals according to their meal ticket. This was evident for 11 (Resident #14, #19, #30, #39, #41, #51, #58, #66, #70, #87, and #92) of 83 trays observed during the lunch meal tray lineThe findings include:On 04/29/2026 at 11:35 AM, an observation of the kitchen lunch tray line revealed [NAME] (Staff #15) started to plate the food. On 04/29/2026 at 12:07 PM, Resident #19's meal ticket was placed on the tray and [NAME] (Staff #16) noted that it indicated the resident was supposed to receive garlic egg noodles as the main food item for the meal. [NAME] (Staff #15) indicated they did not have any garlic egg noodles. Staff #15 gave Resident #19 the regular main for the meal that was on the menu which was turkey.On 04/29/2026 at 12:24 PM, Staff #15 indicated they had finished the unit trays and would start on the dining room trays for those who are eating in the dining room. On 04/29/2026 at 12:33 PM, a follow up observation of the kitchen revealed they ran out of the squash medley vegetable side that was on the menu and meal tickets and were using broccoli as an alternative.On 04/29/2026 at 12:34 PM, an interview with Staff #15 revealed that there were 10 residents (Resident #14, #30, #39, #41, #51, #58, #66, #70, #87, and #92) eating in the dining room who would be receiving broccoli, even though their meal tickets indicated squash medley as the vegetable side.On 04/29/2026 at 1:21 PM, an interview with Food Services Director (Staff #17) revealed that he or the assigned cook reviewed the meal tickets prior to each meal to ensure that any special food requests could be prepared and so that they have enough food that was on the menu for each resident. The surveyor reviewed the concern of the findings identified during the lunch tray line observation with Staff #17 and the Nursing Home Administrator who was present during the interview.

Number of residents sampled: Number of residents cited: Based on observation and interview, it was determined that the facility failed to maintain residents dignity by staff knocking prior to entering their rooms. This was evident for 3 (Resident #48, #67, #73) of 24 residents screened during the initial pool process of the annual survey.The findings include:1) On 04/27/2026 at 9:03 AM, during the initial interview with Resident #73, Geriatric Nursing Assistant (Staff #20) entered the room when the door was closed, without knocking. As Staff #20 noticed the surveyor, she proceeded to say, knock knock knock, after she had already opened the door and walked into the room.On 04/27/2026 at 9:04 AM, further interview with Resident #73 revealed that some of the staff do not knock prior to walking into the room. 2) On 04/27/2026 at 11:59 AM, during the initial interview with Resident #68, Geriatric Nursing Assistant (Staff #4) opened the door and entered the room without knocking. As Staff #4 noticed the surveyor, she proceeded to knock on the side of the door where the handle was, after she had already opened the door and walked into the room.3) On 04/27/2026 at 12:09 PM, during the initial interview with Resident #47, Geriatric Nursing Assistant (Staff #19) opened the door and entered the room without knocking. At the same time, an interview with Staff #19 revealed that she thought both residents were out of the room. On 04/30/2026 at 10:18 AM, the surveyor reviewed the concern with the Director of Nursing and she indicated that she understood.

Based on observation, staff interviews and surveyor record reviews it was determined that the facility failed to develop/implement a comprehensive care plan for a Resident. This finding was found to be evident in 1 (Resident #13) out of 4 Residents reviewed for care plans.The findings include:A Care Plan is a formalized, dynamic document outlining a Resident's health conditions, goals, and specific interventions, created collaboratively by healthcare professionals, patients, and families. The care plan ensures personalized care, tracks progress, and includes medication, treatment plans, and provider information to improve health outcomes and safety, especially for chronic conditions. The key components of a care plan include assessment (identification of Resident needs, symptoms, and medical history), nursing diagnosis (identification of specific patient health problems), goals/desired outcomes (actionable, measurable, and patient-centered targets), interventions (specific, planned actions to be taken by the interdisciplinary care team), and evaluation (regular review of the plan's effectiveness, adjusting as needed). The care plan streamlines care delivery and helps manage long-term needs.On 4/29/2026 at 11:00 AM, the surveyor observed Resident #13 alert, well-groomed, in no distress sitting in a wheelchair in the hall near the nursing station.The surveyor conducted a record review of Resident #13's medical record on 4/30/2026 at 3:45 PM. Review of the medical record revealed that Resident had a fall with left thigh pain at the facility on 2/19/2026, transferred to the hospital on 2/19/2026, and the x-ray done in the emergency room showed left intertrochanteric femur fracture. Additionally, the Resident had surgical intervention on 2/20/2026 for intramedullary nail and fixation of left intertrochanteric femur fracture. Resident #13 returned to the facility on 2/23/2026 from the hospital. Further review of the medical record on 4/30/2026 revealed that there was not a comprehensive care plan for Resident #13 for the left femur fracture and the operative procedure for the intramedullary nail and fixation of the left femur fracture.In an interview with employee #18 at 8:45 AM on 5/1/2026 the surveyor asked who was responsible for the care plan process. Employee #18 indicated that the interdisciplinary clinical team (IDT) was responsible for the care plan process. The surveyor conveyed to employee #18 that Resident #13 did not have a comprehensive care plan for the diagnosis of left femur fracture, and the operative procedure for nailing and fixation of the left femur fracture. Employee #18 acknowledged the surveyor and stated that she would follow up with nursing. Nephrostomy tube is a thin, flexible catheter inserted through the skin of the back into the kidney to drain urine directly into an external bag, bypassing blockages caused by tumors, stones, or infections. The 30-90-minute, ultrasound-guided procedure is usually temporary but requires daily care (cleaning and flushing) and brings risks of infection or blockage, often every three months.Further review of Resident #13's medical record on 5/1/2026, specifically the progress note revealed that Resident had a nephrostomy tube on 12/4/2025 at 17:47 when he/she was readmitted to the facility, and on 2/4/2026 at 22:39 the Resident had a surgical procedure to remove the nephrostomy tube. Review of the comprehensive care plan with revisions did not reveal that Resident #13 had a care plan for a nephrostomy tube or care of the nephrostomy tube during that time.In a follow up interview with employee #18 at 11:20 AM on 5/1/2026 the surveyor conveyed that Resident #13's comprehensive care plan with revisions did not reveal that Resident had a care plan for the nephrostomy tube and the care of the nephrostomy tube. Employee #18 acknowledged the surveyor and stated that she would review the notes as she was not sure of the status of the nephrostomy tube.At 11:30 AM on 5/1/2026 the surveyor conveyed to the Director of Nursing (DON) that review of Resident #13's comprehensive care plan with revisions did not reveal that Resident had a care plan for the left femur fracture and the surgical repair of the left femur fracture, and the nephrostomy tube and care of the nephrostomy tube. DON acknowledged the surveyor and stated that she would review and follow up. At 11:45 AM on 5/1/2026 in an interview with Registered Nurse (RN) Unit Manager #21 the surveyor asked if Resident #13 had a nephrostomy tube, and she stated no, the nephrostomy tube was removed earlier this year. RN Unit Manager #21 provided the documentation regarding the nephrotomy tube from Resident #13's medical record.No additional information was provided by the facility at the time of survey exit.

Based on observation, interviews, and record review, it was determined that the facility failed to provide residents who are unable to carry out activities of daily living (ADLs) the necessary services to maintain personal hygiene. This was evident for 2 (Resident #54 and #109) of 3 residents reviewed for ADLs during the annual survey, The findings include The Minimum Data Set (MDS) is a federally mandated, standardized clinical assessment tool used in Medicare/Medicaid-certified nursing homes to evaluate a resident's functional, medical, psychological, and cognitive status.1.On 4/27/2026 at 11:17 AM Resident #54 stated that a Geriatric Nursing Assistant #23(GNA) puts double diapers on them at night and did so again last night 4/25/27. That GNA #23 worked a double shift, 3-11 and 11-7 shift that night. The resident stated that s/he was developing redness on their peri area and bottom because of the double diapering.A review of resident #54's care plan with initiation dated of 3/13/26 and 3/24/26 respectively, documented that resident has an ADL self-care performance deficit related to (r/t) Impaired balance and has potential for impairment to skin integrity r/t incontinence, fall risk, decreased mobility. Some Interventions were to Keep the skin clean and dry.2. On 4/27/2026 at 12:12 PM Resident #109 also told the surveyor that Staff has been putting two diapers on them because s/he was on diuretics, a medication that removes excess water through increase urination. A review of the admission Minimum Data Set (MDS) with assessment reference date (ARD) of 4/22/26 section GG-Functional ability documented that resident was dependent on staff with personal hygiene and transfers. Further review of the physicians orders also revealed an order dated 4/15/26, it reads: Lasix Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day. In a phone Interview with GNA #23 on 4/28/2026 at 1:58 PM she was asked how often she changes the residents' diapers on her shift, and she said every 2 hours and as needed. She was asked how she identify those who needed to be changed and she said they would put their call lights on, and for the cognitively impaired residents, she would check them. She was asked what could happen if residents are not changed frequently. She stated that they can get redness down there and/or urinary tract infection (UTI). She was asked how many diapers are put on her residents when she changed them and she said one. She was asked if she ever put two diapers on her residents and she said she has not used two. She was made aware that some residents mentioned her name that she uses double diaper on them and asked to explain. She said she cuts out the pull ups and used them like a pad on the residents. On 4/28/2026 at 2:32 PM in an Interview with the Director of Nursing (DON), she was asked about their policy regarding double diapering. She said staff should not be double diapering at all because it's not allowed. She was made aware of the above concerns, and she said it's unacceptable and is a no-no. She indicated that the staff will be suspended and an in-service provided to all nursing staff.

Based on review of medical records and interview with staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Residents #88) of 5 residents reviewed during the annual survey. The findings include:On 04/30/2026 at 8:22 AM: A review of Resident #88's medical record showed that the Medication Regimen Review (MMR) for December 3, 2025, lacked documentation of a review being conducted.The pharmacy had recommended that the Multivitamin be given 4 hours after the Levothyroxine was administered. The recommendation was Please Administer Multivitamin at least 4 hours after the Levothyroxine.A review of the Medication Administration Record (MAR) for April 2026 revealed that Resident #88's Levothyroxine continued to be administered at 6 AM and the Multivitamin at 9 AM, which is only 3 hours apart instead of the recommended 4 hours apart.04/30/2026 at 9:58 AM: Staff #14, the Regional Clinical Nurse, was interviewed and stated they would check on whether Resident #88's December 3, 2025, MRR was addressed.Staff #14 later verified that the pharmacy recommendation regarding Levothyroxine and Multivitamin was not addressed, and the MAR for April 2026 still reflected the times of 6 AM for Levothyroxine and 9 AM for the Multivitamin.Staff #14 verbalized understanding that failing to follow up on the pharmacy recommendation in a timely manner was an issue and confirmed that pharmacy reviews are generally completed monthly.

Based on observations, staff interviews and surveyor record reviews it was determined that the facility failed to ensure that physician medication orders had 1) appropriate indication for usage of the medications and 2) appropriate monitoring and documenting for side effects of medications for a Resident. This finding was found to be evident in 1 (Resident #111) out of 3 Residents reviewed for physician medication orders.The findings include:The surveyor conducted an observation of medication administration on 4/29/2026 at 7:49 AM with Licensed Practical Nurse (LPN) #10 for Resident #111.Apixaban (Eliquis) is an anticoagulant medication, blood thinner.Furosemide (Lasix) is a diuretic medication, water pill.At 10:45 AM on 4/29/2026 the surveyor conducted a record review of Resident #111's medical record. Review of the medical record revealed that Resident had physician medication orders for Apixaban (Eliquis) 2.5 mg by mouth two times a day, and Lasix (Furosemide) 40 mg by mouth one time a day for pleural effusions. The Eliquis order did not have an indication for usage of the medication included in the physician order, and there was not a physician order for monitoring and documenting the side effects for the usage of Lasix.Diltiazem, Hydralazine and Losartan are medications prescribed for hypertension (high blood pressure).Ezetimibe is a medication prescribed for hypercholesterolemia (high cholesterol level in the blood).Tamsulosin is a medication prescribed for benign prostatic hyperplasia (BPH), enlarged prostate.Further review of the medical record on 4/29/2026 for Resident #111 revealed that additional medications did not have indication for usage in the physician orders. These medications were Diltiazem 360 mg 1 capsule by mouth in the evening, Ezetimibe 10 mg 1 tablet by mouth one time a day, Hydralazine 50 mg 1 tablet every 8 hours, Losartan 25 mg 1 tablet by mouth one time a day, and Tamsulosin 0.4 mg 1 capsule by mouth at bedtime. In an interview with Registered Nurse (RN) Unit Manager (UM) #13 at 1:20 PM on 4/29/2026 the surveyor asked what the expectation was for what was included in a physician medication order for a Resident. RN UM #13 stated that the physician medication order should include the medication, dosage, route, frequency, and the indication for the medication. The surveyor reviewed with the RN UM the medication orders for Eliquis, Diltiazem, Ezetimibe, Hydralazine, Losartan, and Tamsulosin for Resident #111 that did not have the indication for usage. The RN UM #13 acknowledged the surveyor and stated that she would follow up. At 11:30 AM on 5/1/2026 the surveyor conveyed to the Director of Nursing (DON) that review of Resident #111's medical record revealed that Resident did not have indications for usage of several medications included in the physician orders. DON acknowledged the surveyor and stated that she would review and follow up. No additional information was provided by the facility at the time of survey exit.

Based on observation and interview, it was determined that the facility failed to ensure food was stored to maintain food safety. This was evident during the initial observation of the kitchen upon survey entry.The findings include:1) On 04/27/2026 at 7:34 AM, an initial observation of the kitchen revealed in the freezer there were french toast sticks, green beans, and chicken patties which were all opened and unlabeled.At the same time, further observation of the kitchen fridge next to the freezer revealed turkey bacon which was opened and unlabeled.On 04/27/2026 and 7:46 AM, further observation of the kitchen on a top shelf above a preparation table revealed a box of, quick creamy wheat, which was opened and unlabeled, plastic square containers with lids of what looked to be oatmeal and creamy wheat, which were opened and unlabeled, all purpose flour opened and unlabeled, and a large jug of, salsa picante, which was opened and unlabeled with the date it was opened. At the same time, further observation of the kitchen fridge with salad dressings had a plastic container with a lid full of an orange substance, but had no label of what it was or the date it was prepared. There was a head of iceberg lettuce that was in a large bag that at one time had approximately 6-8 heads of lettuce, which was opened and unlabeled.On 04/27/2026 at 7:48 AM, an interview with [NAME] (Staff #15) revealed that anytime anything is opened for the first time, the expectation of staff was that it would be labeled with the name of the item and date it was opened, whether it was kept in the same container/bag or put in another container. On 04/27/2026 at 7:53 AM, an observation of the downstairs dry storage room revealed a large opened box lined with a blue bag that had raisins which opened to the air and unlabeled with the date. At the same time, further observation of the dry storage room revealed an opened loaf of rye bread that indicated it was best by March 27th. On 04/27/2026 at 9:38 AM, the surveyor walked around the kitchen with Staff #17 to review the identified opened, unlabeled, and nondated items that were identified during the initial observation. As all of the opened and unlabeled items noted above were shown to Staff #17, he proceeded to label them with the date of 4/27/26. 2) On 04/27/2026 at 7:50 AM, an initial observation of the downstairs dry storage room revealed approximately 15 boxes of various items, frozen items, fruits, and meats that were stacked on the floor. The boxes were all labeled with keep refrigerated, and/or keep frozen. At the same time, Staff #15 was present during the observation. An interview with Staff #15 revealed that the truck had dropped off the items not too long ago and that the Food Services Director (Staff #17) would arrive shortly to put all of the items in their prospective places. On 04/27/2026 at 8:02 AM, the surveyor left the basement dry storage room where the freezer and fridge items were stacked in the room. On 04/27/2026 at 8:18 AM, further observation of the basement dry storage room revealed the freezer and fridge items were still stacked, and Food Services Director (Staff #17) was starting to label the items while stacked with the date. At the same time, an interview with Staff #17 revealed that he normally puts the items away in their prospective places on days when the food service truck delivers the items. On 4/29/2026 at 1:19 PM, an interview with the Food Services Director (Staff #17) revealed that the items delivered by the truck came earlier than normal on 4/27/2026. The surveyor asked if they have a process in place for the items to be put away if delivered early and he was unable to indicate a process that was in place. On 04/29/2026 at 1:20 PM, the surveyor reviewed the concerns with the Nursing Home Administrator and Staff #17.

Based on record review and interview, it was determined that the facility staff failed to ensure resident medical records were accurately documented and maintained according to professional standard of practice. This was evident for 3 (Resident #3 #78 and #13) of 7 residents reviewed for advance directives and medical records accuracy. The findings include: 1.On 04/28/2026 at 7:55 AM, review of Resident #3's medical record revealed a document titled, Social Services Assessment and Documentation, dated 3/20/2025 signed by Director of Social Services #3 that indicated on line 5b. that the resident did not have an advanced directive, on line 5c. that additional conversation regarding advanced care planning was not provided, 5d. that the opportunity to complete an advanced directive was not provided, and 5e. that advanced directive educational materials were not provided to the resident. On 04/28/2026 at 8:14 AM, review of Resident #78's medical record revealed a document titled, Social Services Assessment and Documentation, dated 3/02/2026 signed by Director of Social Services #3 that indicated on line 5b. that the resident did not have an advanced directive, on line 5c. that additional conversation regarding advanced care planning was not provided, 5d. that the opportunity to complete an advanced directive was not provided, and 5e. that advanced directive educational materials were not provided to the resident. On 04/28/2026 at 9:55 AM, an interview with Director of Social Services #3 revealed that all residents were asked about advanced directives and if they did not have one they would be offered materials to formulate one. She further indicated they document it on the, social services assessment, document noted above. On 04/28/2026 at 1:09 PM, the surveyor reviewed the concern with the Nursing Home Administrator and requested any further documentation that would indicate information to formulate an advanced directives were offered to Resident #3 and #78 when they indicated they did not have one. On 04/28/2026 at 1:25 PM, a follow up interview with the Director of Social Services #3 revealed that she felt the template was confusing the way it is read. She further indicated it can be interpreted several different ways when she would document. The surveyor reviewed the concern with #3 along with the Nursing Home Administrator who was also present during the interview. 2. Anticoagulant drugs, commonly known as blood thinners, are medications that prevent harmful blood clots from forming or growing by inhibiting clotting factors in the blood. This medication is used to treat or prevent conditions like stroke, deep vein thrombosis (DVT), and pulmonary embolism (PE). Common types include Apixaban (Eliquis), Rivaroxaban (Xarelto), and Warfarin (Coumadin). Excessive bleeding is the primary side effect of anticoagulant medications. Antiplatelet drugs are medications that prevent blood clots by reducing platelet aggregation (sticking together in the arteries). These medications are crucial for reducing risks of heart attacks, strokes, and cardiovascular events. Common types include Aspirin, Clopidogrel (Plavix), Ticagrelor (Brilinta), and Cilostazol (Pletaal). Key side effects include increased bleeding risk, bruising, and stomach upset. The difference between these 2 medications is antiplatelets keep platelets from clumping, generally preventing clots in the arteries, and anticoagulants (blood thinners) work on different clotting factors to prevent clots in the veins and heart. The surveyor conducted a record review of Resident #13's medical record on 4/30/2026 at 4:10 PM. Review of the medical record revealed that Resident had an active physician order dated 4/1/2026 for Anticoagulant/Antiplatelet Medication – Monitor for discolored urine, black tarry stools, sudden severe headache, nausea & vomiting, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, nose bleeds; Document: Y (Yes) if monitored and none of the above observed; N (No) if monitored and any of the above was observed, select chart code: Other/See Nurses Notes and progress notes findings every shift. Further review of the physician orders for Resident #13 revealed that Resident did not have an active physician order for an anticoagulant medication or antiplatelet medication. A Care Plan is a formalized, dynamic document outlining a Resident's health conditions, goals, and specific interventions, created collaboratively by healthcare professionals, patients, and families. The care plan ensures personalized care, tracks progress, and includes medication, treatment plans, and provider information to improve health outcomes and safety, especially for chronic conditions. The key components of a care plan include assessment (identification of Resident needs, symptoms, and medical history), nursing diagnosis (identification of specific patient health problems), goals/desired outcomes (actionable, measurable, and patient-centered targets), interventions (specific, planned actions to be taken by the interdisciplinary care team), and evaluation (regular review of the plan's effectiveness, adjusting as needed). The care plan streamlines care delivery and helps manage long-term needs. Continued review of Resident #13's medical record on 4/30/2026 revealed that the care plan had a goal that indicated The Resident will remain free of complications related to anticoagulant therapy through review date with an initiation date of 4/21/2026 and a target date of 5/31/2026. Additionally, there were interventions on the care plan that indicated Give medications as ordered, monitor/document for side effects and effectiveness, monitor/document/report PRN any signs/symptoms of complications abnormal bleeding, bruising, petechiae related to anticoagulant use. In an interview with employee #18 at 8:45 AM on 5/1/2026 the surveyor asked who was responsible for the care plan process. Employee #18 indicated that the interdisciplinary clinical team (IDT) was responsible for the care plan process. At 11:30 AM on 5/1/2026 the surveyor conveyed to the Director of Nursing (DON) that review of Resident #13's medical record revealed that Resident was not currently receiving an antiplatelet or anticoagulant medication, but review of the active physician orders and the care plan indicated that Resident #13 was being monitored for side effects and complications related to antiplatelet and anticoagulant medication usage. DON acknowledged the surveyor and stated that she would review and follow up. No additional information was provided by the facility at the time of survey exit.

Based on record review and staff interview, it was the determined that the facility failed to report an incident involving a resident who had a serious injury of unknown source, where abuse or neglect had not been ruled out, to the Office of Health Care Quality (OHCQ) as required. This was evident for 1 (Resident #12) of 13 residents reviewed during a complaint survey.The findings include:The Office of Health Care Quality (OHCQ) is the agency within the Maryland Department of Health charged with monitoring the quality of care in Maryland's health care facilities and community-based programs.On 04/01/2026 at 10:46 AM, a review of Resident #12's clinical record revealed that on 03/23/2026, Resident #12 had an unwitnessed event in the facility. The resident's spouse reported the resident's legs were hanging off the side of the bed and were put back in place. Staff did not witness the event, and the resident could not explain what happened. The resident complained of left leg pain and was sent to the hospital on [DATE] for further evaluation.A review of the Emergency Department (ED) Provider notes dated 03/24/2026 revealed diagnostic imaging that showed an acute left hip periprosthetic (around an artificial joint or implant) fracture, described as a new fracture in the left proximal femur (the thigh bone). The resident returned to the facility on [DATE].Further review of Resident #12's clinical record showed the facility documented that the resident did not have a fall in the facility, and the cause of the injury was not clearly known.On 04/03/2026 at 12:13 PM, during an interview, the Administrator confirmed the 03/23/2026 incident was not reported to OHCQ. The Administrator stated the facility believed the injury happened when the resident's spouse moved the resident's legs and did not consider the event reportable.The findings were discussed with the Administrator and Regional Director of Operations during the exit conference on 04/07/2026.

Based on record review and staff interview, it was determined that the facility failed to complete a thorough and timely investigation of an incident involving a resident who had a serious injury of unknown source. This was evident for 1 (Resident #12) of 13 residents reviewed during a complaint survey.The findings include: On 04/01/2026 at 10:40AM, a review of Resident #12's clinical record revealed that on 03/23/2026, Resident #12 had an unwitnessed event in the facility. The resident's spouse reported the resident's legs were hanging off the side of the bed and were put back in place. Staff did not witness the event, and the resident was not able to explain what happened. The resident complained of left leg pain and was sent to the hospital on [DATE]. Review of Emergency Department (ED) records dated 03/24/2026 showed the resident had an acute left hip periprosthetic (around an artificial joint or implant) fracture. On 04/03/2026 at 11:13 AM, during an interview, the Administrator stated that Resident #12's 3/23/26 incident was discussed at a risk meeting and that he would provide the documentation for review. On 04/03/2026 at 12:02 PM, a review of facility risk meeting documentation showed the facility documented that Resident #12 did not have a fall in the facility. However, the facility did not determine how the injury occurred. Further review showed the incident was discussed on 03/31/2026. There was no evidence to show the facility completed a timely or thorough investigation at the time of the event. On 04/03/2026 at 1:45 PM, during an interview, the Administrator stated the facility believed the injury happened when the resident's spouse moved the resident's legs and did not complete additional investigation to determine the cause of injury. On 04/07/2026 at 11:35 AM, during a follow up interview with the Administrator and Regional Director of Operations, it was confirmed that the incident was discussed in the risk meeting and that no additional investigation was conducted to determine the cause of injury. The findings were discussed with the Administrator and Regional Director of Operations during the exit conference on 04/07/2026.

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) discharge assessments were completed for a discharged resident. This was evident for 1 (Resident #2) of 13 residents reviewed during a complaint survey.The findings include: 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 4/1/26 at 12:12 PM a review of Resident #2's medical record was conducted and revealed Resident #2 was transferred to an acute care facility on 2/3/26. Review of MDS assessments in Resident #2's medical record failed to produce a discharge MDS assessment.On 4/1/26 at 12:15 PM an interview was conducted with the MDS Coordinator. The MDS Coordinator was asked about the discharge assessment and she stated, I did not do one. I have no clue how this fell off the radar.On 4/2/26 at 1:30 PM the Nursing Home Administrator was informed of the concern.

Based on record review, observations and staff interviews, it was determined that the facility failed to ensure implementation of care planned interventions necessary to prevent accidents for a resident identified as high risk for falls. This was evident for 1 (Resident #12) of 3 residents reviewed for accidents during the complaint survey.The findings include:On 04/01/2026 at 10:46 AM, Resident #12's clinical record was reviewed to reveal the resident was admitted to the facility on [DATE] with diagnoses including, but not limited to, altered mental status, hydrocephalus, seizures, intracranial injury, and muscle weakness.Review of Resident #12's care plan revealed the resident had a history of multiple unwitnessed falls, including 01/09/2026, 01/15/2026, 02/12/2026, and 02/19/2026. The fall care plan, initiated on 02/19/2026, included the use of a fall mat for fall prevention.Review of Resident #12's hospital Discharge summary dated [DATE] revealed the resident was transferred to the hospital on [DATE] following an unwitnessed fall and returned to the facility on [DATE] after receiving surgical treatment for a confirmed hip fracture.Review of Resident #12's fall risk evaluations completed on 01/09/2026, 01/16/2026, 02/12/2026, 02/23/2026, and 03/23/2026 revealed the resident was identified as high risk for falls on each assessment.Continued record review revealed that on 03/23/2026, Resident #12's spouse reported that the resident's legs were dangling off the side of the bed. Resident #12 complained of leg pain and was transferred to the hospital, where diagnostic testing confirmed a new left hip fracture. The resident returned to the facility on [DATE].On 04/01/2026 at 1:32 PM, an observation of Resident #12 revealed the resident lying in bed with no fall mat in place on the right side of the bed.On 04/02/2026 at 8:05 AM, a second observation of Resident #12 revealed the resident lying in bed without a fall mat in place on the right side of the bed.On 04/02/2026 at 10:43 AM, during an interview, Unit Manager (UM) #19 confirmed Resident #12 was a high fall risk and should have had a floor mat in place as indicated in the care plan.On 04/02/2026 at 10:50 AM, the surveyor observed UM #19 placing a fall mat on the floor at the right side of Resident #12's bed. During a follow-up interview, UM #19 stated the fall mat was obtained from the supply closet.On 04/02/2026 at 10:59 AM, during an interview, the Assistant Director of Nursing (ADON) confirmed Resident #12 had a care planned intervention for a fall mat and stated the intervention should have been in place. The ADON further stated that if a fall mat is included in the care plan, there should be a corresponding physician order.On 04/02/2026 at 12:02 PM, a review of Resident #12's physician orders revealed no active order for a fall mat.On 04/02/2026 at 12:54 PM, during a follow-up interview, the ADON confirmed there was no prior order for a fall mat and stated a physician order for a fall mat was written the same day on 04/02/2026.On 04/07/2026, the findings were reviewed with the Administrator and Regional Director of Operations during the exit conference.

Based on surveyor review of clinical and administrative records and staff interviews, it was determined that the facility failed to maintain a safe environment for resident #76. This deficient practice placed the resident at risk for elopement and serious harm. This finding was evident for 1 of 13 (#76) residents reviewed for accidents during the survey and was identified during the investigation of facility reported incident #MD 904. Review of the facility's plan of correction implemented after the facility gained knowledge of the incident resulted in the deficiency being cited as past non-compliance. The findings include: A wander guard system is an alarm system used to alert staff if a resident who has been determined at risk for elopement is trying to leave the facility or wander into a restricted area. A transmitter is placed on the at-risk resident (typically on a band around the wrist or the ankle) and when the resident approaches the door way or area equipped with a wander guard sensor, an alarm sounds to notify staff. On 03-27-19, surveyor review of the clinical record for resident #76 revealed an elopement assessment, dated 12-07-18, that stated the resident was at risk for elopement. On 12-07-18, there was a physician's order to check for wander guard placement every shift. In addition, the clinical record revealed a care plan, dated 12-08-18, that stated potential for elopement related to non-compliance. The care plan stated that the facility implemented interventions to prevent elopement. These interventions included assessing, documenting, and reporting to the resident's doctor any risk factors for potential elopement, applying a wander guard and checking for placement, redirecting as needed, taking a photo of the resident to maintain on file for identification purposes, placing a copy of the resident's face sheet with a photo at the reception desk, and obtaining a psych consult as needed. Further review of the clinical record revealed a physician certification related to substitute decision making, medical condition, and treatment limitations that stated the resident was deemed as unable to comprehend and make decisions on 12-18-18 and 12-19-18 by two separate physicians. Additionally, the clinical record revealed a safe smoking evaluation was performed by facility staff on 12-18-19, which assessed resident #76 as a dependent smoker. The evaluation stated the resident required supervision with smoking. On 03-27-19 at 01:50 PM, interview with GNA #1 revealed he/she saw resident #76 on 12-19-18 around 7 AM outside the front entrance by himself/herself. GNA #1 stated that resident #76 had just finished smoking a cigarette and GNA #1 redirected the resident back into the building because they should not have been outside by themselves. GNA #1 stated resident #76 was wearing a wander guard bracelet and set off the wander guard alarm when they went back into the building. GNA #1 stated that he/she immediately told the charge nurse that the resident was outside the building unattended by staff. There was no evidence that the charge nurse assessed resident #76 after he/she was observed outside of the building unattended. Furthermore, there was no evidence that the facility provided increased supervision or altered safety interventions to prevent further elopement attempts. The charge nurse assigned to resident #76 was unavailable for interview. Review of a nurse's note, written on 12-19-18 at 06:01 PM, revealed the resident was last seen by the charge nurse in the facility on 12-19-18 around 07:40-07:45 AM. At 10:40 AM on 12-19-18, the facility staff were unable to locate the resident on the facility premises after staff conducted a search. The facility's administration were notified and the police were called. In addition, the resident's attending physician and legal guardian were notified of the resident's elopement from the facility. Review of the facility's interview with the receptionist revealed that he/she came into the facility at 7:12 AM on 12-19-18 and did not see the resident that day. Further review of the clinical record revealed a nurse's note, written on 12-20-18 at 6:37 PM, which stated that resident #76 returned to the facility around noon on 12-20-18. The resident was assessed as stable by the nursing staff and physician. On 03-28-19 at 01:40 PM, surveyor interview with the Director of Nursing revealed that the facility was unable to determine how the resident eloped from the facility premises unnoticed. However, there was no evidence that the facility questioned resident #76 regarding how he/she was able to leave the building unnoticed. Upon the resident's return to the facility on [DATE], the staff noted that the resident was no longer wearing a wander guard bracelet. Resident #76 was immediately provided a new wander guard bracelet that was more tamperproof. On 03-28-19 at 4:10 PM, surveyor interview with the administrator revealed the front desk was staffed with a receptionist between the hours of 7 AM to 9 PM. From 9 PM to 7 AM, the main entrance was locked and the nursing supervisor must unlock the door to allow anyone in or out of the facility. Immediate actions taken by the facility on 12-19-18 included: A quick census was conducted and all the residents on the units were accounted for. All door alarms and wander guard alarms were checked for proper functioning. The maintenance staff will check the wander guard alarms on a daily basis. The nursing staff will check placement of wander guard bracelets of residents every shift. The administration performed a review of elopement policies and procedures. A photo binder of residents that were assessed as elopement risks was posted at the front desk. The front desk requires staff to open the door to the main entrance for anyone exiting the building. On 12-20-18, following resident #76's return to the facility, the staff replaced resident #76's wander guard bracelet with a more tamperproof device. Facility staff also replaced the wander guard bracelets of other residents with a more tamperproof device. On 12-21-18, the assistant Director of Nursing provided clarification and training to some of the facility staff regarding the facility's elopement and leave of absence policy, completion of an incident report, and documentation and follow up of residents who eloped. Additional training sessions were conducted with the remaining facility staff by the assistant Director of Nursing on 12-26-18 and 12-27-18. An elopement drill was performed with facility staff on 01-04-19. On 01-24-19, resident #76 was discharged from the facility. The Director of Nursing and Assistant Director of Nursing will submit and review the audits with QAPI (quality assurance and performance improvement) committee every month for three months or until complete compliance is achieved as determined by the committee. The facility's compliance date was 01-24-19. 2. Based on surveyor review of the clinical record, surveyor observations, review of the facility policy and procedures and interview with resident #53's family member and facility staff, it was determined that the facility failed to determine the cause of the resident #53's fall from the sling during a mechanical lift transfer. In addition, the facility failed to implement possible corrective measures in a timely manner to reduce the risk of falling during a mechanical lift transfer. This finding was evident for 1(#53) of 4 residents observed during the survey of a mechanical lift transfer The findings include:. On 03-28-19 at 11:40AM, surveyor observation on the East unit hall revealed that resident #53 was found on the floor near the entrance of the resident's room. Staff members, as well as the resident's attending physician, were observed kneeling at the resident's side. In addition resident #53's family member was observed in the hall next to the resident, crying and yelling they dropped my mom. The Hoyer (mechanical lift) lift device was positioned near the resident's lower extremities with the sling partially still attached to the device's hooks. Further observation revealed that resident 53's attending physician was observed performing a head to toe assessment of the resident, while staff ensured that the resident was comfortable by positioning a pillow under the resident's head and keeping the resident covered. The attending physician ordered, after completion of the assessment, for staff to transfer the resident back to bed. A different mechanical lift device was used, as well as another sling was applied under the resident. Then staff members were observed attaching the sling to the lift and then proceeded to mechanically lift the resident to bed with staff members' assistance. The resident verbalized responses both to the physician and staff members when asked. On 03-28-19 at 1PM, surveyor interview with LPN (Licensed Practical Nurse) # 1 revealed that 2 GNAs (Geriatric Nursing Assistant) had begun the process of transferring resident #53 from the gerichair (recliner) with the use of the mechanical lift and as the GNAs had started to move the lift from the gerichair, the resident came out of the sling. The attending physician, who was present in the facility at the time, was able to conduct an assessment of the resident after the incident. Further interview revealed that resident #53 only complained of pain to the left knee. The physician ordered an X-ray of the left knee and the Tylenol administration as needed. On 03-28-19 at 1:20PM, interview with the attending physician revealed that he/she was able to respond quickly and complete an assessment. Further interview revealed the results of the attending physician included no abnormal findings and only a complaint of pain to the left knee. An X-ray of the left knee and Tylenol administration for pain was ordered and to await X-ray results for any further intervention. Surveyor observation and interview of resident #53 on 03-28-19 at 3:17PM revealed the resident resting in bed and watching TV. Resident was found to be alert to name and place only and complained of left knee hurting earlier in the day, but only sore at the present. The resident was uncertain how he/she ended up on the floor, but recalled that his/her family member had been present and was upset. Interview with the resident's family member on 03-28-19 at 4PM revealed that the resident had returned from [MEDICAL TREATMENT] and was still in the gerichair with the mechanical lift sling underneath the resident. As staff proceeded to attached the rings of the sling to the lift, the family member stated that all 4 rings of the sling were not attached to the 4 prongs of the mechanical lift prior to the lift mechanism, but had not said anything to the GNAs at the time of the lift. The family member when asked, denied that the mechanical lift sling had appeared torn or ripped at the time of the lift. On 03-28-19 at 4:15PM, interview with the facility's administrator and the facility's consultant nurse manager revealed that witness statements were obtained from GNA (Geriatric Nursing Assistant) #3 and #4 , who had performed the mechanical lift transfer. Further interview revealed that the resident had not had fallen, but staff had lowered the resident to the floor. The mechanical lift used was removed immediately from further use after the incident. In addition, all mechanical lifts within the facility had received their annual maintenance in (MONTH) (YEAR) with the next scheduled maintenance check due in (MONTH) 2019. A request by the surveyor was made for a list of all current facility residents that require mechanical lift transfers, as well as an inventory list of all available mechanical lift slings and the current supply of mechanical lifts within the facility. Record review on 03-28-19 for resident #53 revealed staff documentation of transferring assessments for resident #53 that included the transfer requirement for 2 aides assist to transfer to lift the resident during transfers (from and to chairs) with the transfer mode of a mechanical lift (Hoyer lift). Further review of the comprehensive plan of care for Self Care Deficit revealed that the resident was totally dependent for transfers with 2 persons and the use of a Hoyer lift. On 03-29-19, review of the facility's incident report for 03-28-19 at 11:34AM revealed the incident type documented as a fall (witnessed) and the following description of events. Resident was getting transferred by (2 GNAs) Hoyer lift and resident's left leg slide off the Hoyer pad. Resident was immediately caught and re-positioned by the staff members. Family was by resident's room. Nurse assessed resident. no apparent injuries noted. Resident VS WNL (vital signs within normal limits) in stable condition, continue P[NAME] (Plan of Care). Further review revealed documentation that there was no apparent injury, and at time of assessment there was pain in the resident's left leg. Review of Incident and Accident Investigation - Employee/Witness Interview with GNA # 3 revealed that, on 03-28-19 around 11:30AM, resident #53 was being transferred from the gerichair using a Hoyer lift with assistance from GNA # 4. During the transfer, the resident's legs slid off the lift sling and then GNA # 3 grabbed the resident immediately with the resident's upper body in GNA #3's arms, while both GNAs proceeded to assist in the lowering of the resident to the floor. Further review of Employee/Witness Interview of GNA # 4 revealed that, on 03-28-19, the resident was transferred from the gerichair using a Hoyer lift with GNA # 3. During the transfer, the resident's legs were sliding off the sling and GNA #4 held the resident immediately, while GNA # 3 was holding the resident's upper body and both lowered the resident to the floor safely. The resident's daughter who was present started screaming when the incident occurred. On 03-29-19 at 11:45AM, surveyor interview of GNA #3 and GNA #4 revealed that during the transfer of resident #53 on 03-28-19, as the resident was being mechanically lifted from the gerichair, the side of the sling began to tear. However, both GNAs were able to catch the resident and lower the resident to the floor on their own. The resident did not hit the floor, but was grabbed by both GNAs and then lowered to the floor. In addition, when asked if all 4 hooks were attached to the lift's 4 prongs prior to the lift, both GNAs responded that yes all hooks were attached. Further interview revealed both GNAs did not notice a tear in the sling initially at the time of the lift process, since the sling was already applied by the previous shift staff members who had transferred the resident into the gerichair in order to transport the resident to [MEDICAL TREATMENT]. Further surveyor review of the clinical record on 03-29-19 revealed the 03-28-19 X-ray results of resident #53's left knee revealed no evidence of a fracture. In addition, there were no new physician orders , but to continue the administrator of Tylenol 650 mg as needed for pain. Review of the facility's procedures for lift equipment revealed the annual preventive maintenance service report for equipment inspection and calibration checks were conducted on 04-15-18, with results that all mechanical lift equipment was found in good condition. Review of the facility's training and inservices revealed a yearly computerized training on Accident Prevention as well as in class training with licensed staff on Accident Prevention with lift equipment last completed on 01-16-19. In addition, further review of training revealed, at the time of a new employee's orientation to the facility, there was a general training in Accident Prevention and Body mechanics provided. On 03-29-19 at 4:30PM, interview with the facility's administrator and the Director of Nursing (DON) revealed that the Hoyer (mechanical) lift used with resident #53 on 03-28-19 was taken out of further use since the incident, until a completed assessment of the lift could be conducted. In addition, the sling used for the resident on 03-28-19 at the time of the incident had been discarded after the incident. No additional information was provided. However, despite the conflicting statements obtained by the surveyor from GNA #3 , GNA #4 and resident #53's daughter of the incident, the facility failed to determined the cause of the resident's fall from the sling. In addition, the facility failed to implement possible corrective measures in a timely manner to reduce the risk of falling during a mechanical lift transfer.

Based on surveyor tour of the facility kitchen, review of the closed resident record and the facility's policy and procedure, and interview of the facility staff, it was determined that the facility staff failed to accommodate resident #140's food allergy. This finding was identified during the investigation of facility reported incident MD 570, and is valid. The findings include: On 09-12-18, review of resident #140's closed record revealed that the resident was admitted to the facility following a hospitalization in (MONTH) (YEAR). Since the hospital transfer summary stated that the resident was allergic to seafood, an order was written to specify resident #140's food allergy upon admission. Review of the facility's policy and procedure regarding food allergies revealed that, once the food allergy has been identified, a meal ticket shall be generated for the next meal service and the allergy will be reflected on the meal ticket. Review of resident # 140's initial nutritional assessment, dated 08-20-18, revealed that seafood was listed as a food allergy. A new order was written on the same day to provide a sandwich at bedtime for the resident. Further review of the clinical record and the facility's investigation revealed that resident #140 was found with a swollen tongue and slurred speech on 08-21-18 at 1 AM after the resident took a bite of a tuna sandwich prepared by kitchen staff. The resident reported difficulty breathing. Staff called 911 and the resident was transferred to the hospital. On 09-12-18 at 12 noon, interview of staff #3 revealed that he/she put a tuna sandwich into resident #140's paper bag on 08-20-18 at 2 PM. He/she then stapled resident #140's meal ticket on the paper bag. On 09-13-18 at 7:15 AM, interview of staff #2 revealed he/she adjusted resident #140's face mask on 08-21-18 at 12:45 AM and left the room. Then, staff #1 called him/her for assistance. Staff #2 observed that resident #140's tongue was swollen with slurred speech. The resident complained of difficulty breathing. 911 was called and the resident was sent to the hospital. Staff #2 stated he/she observed a paper bag on the resident's bedside table on 08-21-18 at 1:07 AM. The meal ticket, which was stapled on the paper bag, listed that resident #140 was allergic to seafood. On 09-13-18 at 7:30 AM, interview of staff #1 revealed he/she found resident #140 lying in bed on 08-21-18 at 1 AM. The resident handed him/her a sandwich and asked what the sandwich was made of. Staff #1 stated the sandwich had a fishy smell and observed a paper bag on resident #140's bedside table with a meal ticket stapled on the paper bag, which specified the resident was allergic to seafood. Staff #1 further stated that the resident's tongue was swelling and the resident complained of difficulty breathing. He/she went to staff #2 and asked for assistance immediately. Based on review of the hospital record, resident #140 was admitted to the hospital because of an allergic reaction. On 09-12-18, review of the facility's investigation revealed that the Director of Nursing (DON) conducted an investigation on 08-21-18 and concluded that staff #3 failed to review resident #140's food allergy. As a result, a tuna sandwich was given to resident #140 who was allergic to seafood. An action plan was developed, which was as follows: 1. Training was provided by the food service manager on 08-21-18 to all the kitchen staff related to food allergies. 2. Training was provided by the Quality Assurance nurse on 08-21-18 to all the nursing staff related to food allergies and meal tray tickets. 3. An audit was completed on 08-22-18 to verify all residents with food allergies. 4. A new monitoring system was developed and implemented on 08-21-18. Nursing staff were required to review meal tickets and check the food items in the paper bags at 10 AM, 2 PM and 7 PM when delivered from the kitchen to the nursing station. On 09-12-18 at 5 PM, a tour of the kitchen was done in the presence of the kitchen manager and staff #3. A tray, filled with 9 paper bags without meal tickets, was observed in the fridge. Staff #3 stated that these paper bags were prepared for the residents, who were scheduled for the first shift of [MEDICAL TREATMENT] the following day. The kitchen manager then explained that the first shift of [MEDICAL TREATMENT] was 7 AM. On 09-13-18, review of the audit report revealed no documentation that the nursing staff reviewed the meal tickets and checked the food items, which were in the paper bags when delivered from the kitchen at 7 AM. On 09-13-18 at 7:15 AM, interview of staff #1 revealed that he/she did not sign off when the paper bags were delivered daily at 7 AM. Any nursing staff could deliver paper bags to residents listed on the paper bags. On 09-13-18 at 8 AM, interview of the kitchen manager revealed no further information as to why there was no documentation that all the paper bags were being checked daily at 7 AM for food allergies. On 09-13-18 at 12 noon, interview of the administrator revealed no additional information.

Based on staff interviews and review of policies, medical record and other pertinent documentation the facility implemented noncompliant practices for admission and discharges that allowed staff to function far outside their allowed scopes of practice admitting and discharging residents based on billable bed availability with no clinical oversight and with no consideration for resident needs. This concern resulted in rights violations for 2/16 residents reviewed during survey, and the noncompliant processes and practices placed all residents at increased risk for serious harm and possible death. The noncompliant admission and discharge practices which were codified and which affected Resident #1 and Resident #2 resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:20 PM on 1/18/17; and the facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 11:49 PM on 1/18/17 while surveyors remained onsite. The plan included: - The facility conducted an immediate audit of all residents at risk for elopement to ensure that appropriate interventions were in place. - WanderGuard systems and locking door mechanisms are to be checked weekly. - Admissions staff were educated on consent requirements and on admission criteria. - A process was instituted where the Administrator will ensure consents are obtained before admissions. - Discharge planning staff were educated on consent, need to obtain bed availability in writing when resident is discharging, and need to start discharge planning process on admission. - Physicians will be reeducated on importance of providing discharge orders timely. - All staff to be reeducated on policy that elopement and elopement attempts must be documented in the medical record. DON will review elopement attempts and/or events in the facility morning meetings. - Discharge planning notes will be reviewed in morning meeting for any resident to be discharged to ensure discharge is planned and safe. - Administrator will now also review each discharge prior to discharge to ensure acceptance of resident at next provider of care as applicable. - The DON will audit three discharges per week to determine if policies are followed and audits will be reported into the facility QA Committee for oversight. The survey findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident ' s needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions/items. Each triggered care area must then be assessed in order to determine if care planning is needed; and if so to drive an effective plan that will ensure the assessed needs of each resident are met when care is delivered. 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. All staff must review and understand the plan so that care is delivered in a consistent manner across all days, shifts and disciplines. Resident dumping is the act of discharging a resident for reasons not allowed in regulation and often to inappropriate and unsafe locations. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. The Wander Guard management system incorporates a sensor that triggers an alarm when the sensor is detected by a monitoring device. Staff can ensure that vulnerable residents at risk for harm if they leave a facility building wear the sensor. The monitoring devices which detect the sensors are typically placed at potential exit locations so that staff will be alerted if residents wearing the sensor attempt to exit the building. 1. Without consent or assessment, unqualified facility staff admitted a cognitively impaired resident (Resident #1) for whom the facility did not have capability to meet the resident ' s known clinical needs. On 1/18/17 surveyors requested all admission process policies and were provided the facility Admission Criteria Policy. The policy was last reviewed and updated 8/19/14. The policy listed categories of resident conditions and [DIAGNOSES REDACTED]. The policy indicated that the facility accepts patients into the secure units when clinically indicated and appropriate based on hospital assessments. However, this facility does not have a secure unit and therefore does not have any capability to accept residents to a secure unit. The admission criteria policy also provided no staff guidance about accountability for admission process. Resident #1 did not have decision making capacity. Documentation from the hospital admission immediately prior to this nursing home admission indicated that the hospital assisted in obtaining guardianship for the resident ' s son and hospital record documentation revealed that the resident ' s son was the resident ' s decision-maker. Soon after admission to the nursing home, two physicians corroborated in a formal certification that resident #1 did not have decision-making capacity. Both physicians signed the certification on 10/11/16. Hospital documentation sent to the facility for review in making the decision for the possible admission, revealed multiple hospital care planning notes (including notes entered on 10/7/16, 10/8/16, 10/9/16, and 10/10/16) documenting that Resident #1 had intermittent agitation and hallucinations, and that he/she needs to go to facility with dementia unit . Observation of the nursing home on 1/18/17 and interview with the Director of Nursing at 12:45 on 1/18/17 revealed that this facility does not have a secure (locked) unit. In interview with the Administrator on 1/18/17, he reported that the Admissions Coordinator has a degree in Business Administration and is not clinical. In interview on 1/18/17 at 10:00 AM, the Admissions Coordinator stated that she with assistance from the Administrator (a physical therapist with additional training in health care administration) decides who is and who is not admitted . She stated that only if she has a clinical concern that she can ' t figure out does she consult with the Director of Nursing (DON). In interview with the Director of Nursing at 12:45 PM on 1/18/17, she also corroborated that the Admissions Coordinator and Administrator determine who can and cannot be admitted and that she only gets involved if they bring a specific concern to her. None of these processes were documented in the facility admission policy. In interview on 1/26/17 at 10:45 AM, the Medical Director, who was the attending for Resident #1, indicated that she too does not necessarily review information regarding new admissions and that staff do not always notify her of pending admissions. She reported that the Admissions Manager and an NMS Liaison review the resident ' s record and decide whether or not to admit. Thus, the Medical Director who is responsible for facility policy had a different understanding than staff regarding accountability for decisions about admissions. Compounding the concern further, in interview on 1/26/17 at 10:14 AM, the Admissions Manager indicated that she does not keep any notes regarding communication with hospitals seeking placement for patients they are discharging. She reported that she keeps a spreadsheet documenting only the resident name, where they were transferred to/from, date of transfer, reason for transfer, and the name of the facility staff liaison. No facility policy directed that communication with hospital in the review of potential admissions must be documented. In interview on 1/18/17, when asked if the facility evaluated the need for a secure unit for Resident #1, the Admissions Coordinator inaccurately reported that nothing in the hospital record stated they needed a locked unit. Thus, although the hospital documentation specified that Resident #1 required placement on a secure unit, no facility documentation was kept of communication with the hospital or of any review of the hospital documentation. With the Admissions staff denying any knowledge of the hospital documentation specifying the need for a secure unit, no clinical staff with medical or nursing assessment skills and qualifications was made aware, and no clinical staff ever questioned, assessed or evaluated if the placement to this facility which has no secure unit was safe and appropriate for this resident. Review of the medical record revealed that the three day qualifying hospital stay (qualifies resident for Medicare benefit) had been from 10/7/16 through 10/10/16. The resident was admitted by facility staff at 4:45 PM on 10/10/16 and the physician order to admit to the nursing home was entered into the nursing home medical record on 10/10/16 at 9:02 PM. Review of the nursing home admission agreement revealed that it was never signed to evidence consent by the resident ' s son for the resident ' s care and treatment. In interview on 1/18/17, the Administrator reported (and provided documentation showing) that staff was unable to reach the responsible party and that was why the admission agreement was never signed. The single page document tracking the attempts to contact the RP indicated that a Social Services Assistant called the RP on 10/11/16 and left a voice message. The document then indicated that no attempts were made on 10/12/16 because the resident was out of the facility (at the hospital for evaluation after a fall). Next, the document revealed that on 10/14/16 the coordinator staff called and spoke with the RP and documented RP may stop by this weekend but if not the RP will need the admission packet mailed out. No verbal request for consent was ever documented including during this call, and no further attempts to get the agreement signed were documented. No policy provided to the survey team, specified that the facility will not admit residents without consent consistent with state and Federal requirements. 2. The facility failed to ensure staff documented and reported an elopement attempt when resident #1 was able to get out of the building, failed to conduct any investigation of the elopement attempt, and failed to immediately ensure the building was secure after the elopement attempt On 1/18/17 surveyors requested all elopement risk policies and were provided the facility policy entitled Elopement Prevention/Intervention which was last updated 3/1/16. The policy did not provide staff any specific guidance on expectations when a resident attempts to elope but does not fully leave the premises, including those instances where residents get outside of the building but is then brought promptly back in by staff. Review of the medical record revealed that on 10/11/16 at 3:24 PM Resident #1 was assessed at risk for elopement and use of a WanderGuard system was implemented. Per staff interviews with the Social Services Manager, Discharge Planner, and QA Director (all on 1/18/17) the resident at some point got out of the building despite the use of the WanderGuard system. The event was never documented by any staff and no-one interviewed could recall exactly when the event occurred. The event evidenced, as had been documented in the hospital documentation provided before admission, that the use of a WanderGuard system was ineffective to keep Resident #1 safe. In interview on 1/18/17 at 9:20 AM, the Discharge Planner and Social Services Manager reported they were working when he/she left the building and went across the parking lot and passed the neighboring [MEDICAL TREATMENT] building. They reported that many staff members were involved in bringing him/her back inside and calming him/her down, including the Administrator, physical therapy staff and multiple nurses. The Discharge Planner stated that after they got him/her back into the building, she got him a soft drink which he/she likes and that helped calm him/her down. Despite the occurrence of an elopement attempt where the resident got completely out of the building, review of the medical record on 1/18/17 revealed that no concurrent review note was opened to ensure review of facility processes and follow up for the resident ' s needs, no nursing notes documented the event, and the resident care plan was not updated following the event where he/she was able to leave the building despite use of the WanderGuard system. Further, in interview on 1/18/17, the facility QA nurse acknowledged that there had been no investigation of the event. 3. The facility failed to provide any discharge planning services for Resident #1. Review of the medical record revealed that no discharge planning services were provided as required, as no discharge planning notes were entered through the resident ' s entire admission. The only discharge note in the medical record was entered after discharge on 10/20/16 at 10:21 AM. This note documented, discharged : Resident was discharged on [DATE] to NMS Hagerstown. After searching with electronic record access during 12:45 interview on 1/18/17, the Director of Nursing corroborated that there were no discharge planning notes in the medical record for Resident #1. Policies consistent with regulatory requirements for discharge planning services must be developed and followed to ensure the facility meets minimum requirements for care and services it provides. 4. With no documented rationale for discharge, no discharge planning or preparation, no discharge order, and no consent facility staff discharged Resident #1 and drove him/her to another facility in a distant county that also did not have the capability to meet his/her needs. After staff admitted the resident with no clinical review, no order, no consent, and with ineffective screening measures to ensure the facility could meet the resident ' s needs (where he/she needed the secure unit), on 10/19/17 staff transferred Resident #1 to another sister-facility (same corporate ownership). A 10/19/17 note in the nursing section of the medical record revealed that the transfer was not urgent as Resident #1 was stable at the time of the discharge. This note documented that Resident #1 was calm and cooperative with care, no behavioral issues noted. Safety and falls precautions (were) maintained during transport. Further, the resident was noted as alert and verbally responsive, appears in no distress. Breathing even and unlabored, lung sounds clear bilaterally upon auscultation. Abdomen soft and non-tender, bowel sounds present in all quadrants. Skin warm and dry to touch. A discharge note entered at 4:38 PM on 10/19/17, documented that the resident was discharged and the time of discharge was 4:00 PM. The note continued that the resident was discharged by car with NH staff and stated the reason for the discharge was for admission. The note documented that the Physician and/or RP notified in standard text, and added in narrative that the physician was notified but that the responsible party actually was not reached and therefore was not notified and consent to move the resident was not obtained. Additionally but closely related, staff also failed to ensure that the responsible party consented not only to the discharge but also to the admission into the next location for care. Although staff documented the physician was notified at the time of the discharge, review of the medical record revealed that there was no physician order allowing staff to discharge the resident at the time that staff drove the resident to the next nursing home. A physician order was entered into the medical record at 6:42 PM on 1/19/16 (nearly three hours after staff drove the resident from the nursing home). The rationale for the decision to transfer the resident was not documented by any staff, anywhere in the medical record prior to the discharge. Review of the record revealed that the physician entered a discharge note at 10:48 AM on 10/20/16 (after the discharge) indicating that the resident had to be discharged to another facility as (he/she) requires closed unit. With insufficient documentation about the rational and circumstances around the discharge, on 1/18/17, when surveyors requested to interview the staff that drove Resident #1 from the nursing home, the Administrator was also unable to determine just what staff it might have been that drove the resident from the facility on 10/19/17. This was also not documented. In interview with staff at the next facility where resident #1 was driven on 10/19/16, the staff stated that she called the responsible party after Resident #1 had arrived. The staff member said that the resident ' s son was angry and said that he had not been told his parent was being transferred. Without notice or consent, his parent was moved nearly 70 miles further away from the family. At the time of discharge, facility staff had also failed to conduct sufficient discharge preparation as required to ensure the resident was actually going to safe location (in this case a bed on a secure unit). Although the explicit reason for the transfer was the need for the resident to be on a secure unit for safety, at the time of the discharge no bed was available on the secure unit at the receiving nursing home. Therefore, even after putting the confused resident through the discharge and change in his/her home; the resident was still placed on an unsecured, open unit with the use of a WanderGuard which had already proven ineffective prior to the admission on 10/10/16. Policies governing facility admission and discharge practices, consistent with regulatory requirements, must be developed and followed to ensure the facility meets minimum requirements for the care and services it provides. 5. By policy, in effect since 4/11/06 and last revised on 12/1/13, the facility has routinely issued inappropriate notices of intent to discharge residents in their care for non-payment when non-payment has not actually occurred. This facility policy specifically requires that the facility be paid in advance and if a resident might not be able to pay in advance in the future when the prescribed 100 day Medicare coverage ends, notices are issued early to allow for immediate discharge when the 100 day Medicare payment benefit ends. The regulations do not allow facilities to preemptively issue notice to evict a resident on the basis that they might not receive payment in advance when the Medicare coverage period ends. The facility Notice of Involuntary Discharge Policy documents that it is the policy of (NMS) that 30 days prior to the last covered day of service, where payment has not been made in advance (and third-party coverage is ending), a resident will receive notice of intent to involuntarily discharge the resident.

Based on interviews with facility staff, and staff from another faclity. and review of medical record and other pertinent documentation, the facility violated resident rights by developing and employing noncompliant systems for admissions, discharges and provision of care that resulted in all of the following. (1) Without clinical review by qualified staff, with no oversight or order from the physician, and with no notification or consent from the responsible family, non-clinical facility staff admitted a cognitively impaired resident (Resident #1) for whom the facility did not have capability to meet his/her known clinical needs. (2) The facility failed to ensure that the responsible party was able to participate in decisions about care for Resident #1, when the resident was admitted , was readmitted and then was discharged over a nine day period without ever obtaining consent. (3) The facility failed to provide any discharge planning services for Resident #1 through any consultation with the responsible party. (4) With no discharge planning, no discharge order, no notice or consent from the responsible party, and woefully insufficient preparation, facility staff discharged Resident #1 by driving him/her to another facility in a distant county that also did not have the capability to meet his/her needs; and (5) Without providing necessary discharge planning services, the facility issued a notice of intent to involuntarily discharge Resident #2 on 8/11/16, and then on 10/26/16 inappropriately discharged Resident #2 to a local hospital emergency department by sending him/her and then refusing to accept the resident back for payment related concerns. These interrelated concerns were evident for 2/16 residents reviewed during survey. The rights violations associated with noncompliant admission and discharge practices resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:20 PM on 1/18/17; and the facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 11:49 PM on 1/18/17 while surveyors remained onsite. The plan included: - The facility conducted an immediate audit of all residents at risk for elopement to ensure that appropriate interventions were in place. - WanderGuard systems and locking door mechanisms are to be checked weekly. - Admissions staff were educated on consent requirements and on admission criteria. - A process was instituted where the Administrator will ensure consents are obtained before admissions. - Discharge planning staff were educated on consent, need to obtain bed availability in writing when resident is discharging, and need to start discharge planning process on admission. - Physicians will be reeducated on importance of providing discharge orders timely. - All staff to be reeducated on policy that elopement and elopement attempts must be documented in the medical record. DON will review elopement attempts and/or events in the facility morning meetings. - Discharge planning notes will be reviewed in morning meeting for any resident to be discharged to ensure discharge is planned and safe. - Administrator will now also review each discharge prior to discharge to ensure acceptance of resident at next provider of care as applicable. - The DON will audit three discharges per week to determine if policies are followed and audits will be reported into the facility QA Committee for oversight. The survey findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident ' s needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions/items. Each triggered care area must then be assessed in order to determine if care planning is needed; and if so to drive an effective plan that will ensure the assessed needs of each resident are met when care is delivered. 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. All staff must review and understand the plan so that care is delivered in a consistent manner across all days, shifts and disciplines. Resident dumping is the act of discharging a resident for reasons not allowed in regulation and often to inappropriate and unsafe locations. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. The Wander Guard management system incorporates a sensor that triggers an alarm when the sensor is detected by a monitoring device. Staff can ensure that vulnerable residents at risk for harm if they leave a facility building wear the sensor. The monitoring devices which detect the sensors are typically placed at potential exit locations so that staff will be alerted if residents wearing the sensor attempt to exit the building. 1. Without consent or clinical assessment, the facility admitted a cognitively impaired resident (Resident #1) for whom they did not have capability to meet the resident ' s known needs. Resident #1 did not have decision making capacity. Documentation from the hospital admission immediately prior to this nursing home admission indicated that the hospital assisted in obtaining guardianship for the resident ' s son and hospital record documentation revealed that the resident ' s son was the resident ' s Responsible Party (RP). Soon after admission to the nursing home, two physicians corroborated in a formal certification that resident #1 did not have decision-making capacity and both physicians signed the certification on 10/11/16. Hospital documentation sent to the facility for review in making the decision for the possible admission, revealed multiple hospital care planning notes (including notes entered on 10/7/16, 10/8/16, 10/9/16, and 10/10/16) documenting that Resident #1 had intermittent agitation and hallucinations, and that he/she needs to go to facility with (a) dementia unit . Observation of the nursing home on 1/18/17 and interview with the Director of Nursing at 12:45 on 1/18/17 revealed that this facility does not have a secure (locked) unit. In interview with the Administrator on 1/18/17, he reported that the Admissions Coordinator has a degree in Business Administration and is not clinical. In interview on 1/18/17 at 10:00 AM, the Admissions Coordinator stated that she with assistance from the Administrator (a physical therapist with additional training in health care administration) decides who is and who is not admitted . She stated that only when she has a clinical concern that she can ' t figure out does she consult with the Director of Nursing (DON). In interview with the Director of Nursing at 12:45 PM on 1/18/17, she also corroborated that the Admissions Coordinator and Administrator determine who can and cannot be admitted and that she (the DON) only gets involved if they bring a concern to her. Compounding the concern with admission decisions having been delegated to a non-clinical coordinator with no clinical or medical oversight, in interview on 1/26/17 at 10:14 AM, the Admissions Manager stated that she does not keep any notes regarding communication with hospitals seeking placement for patients discharging from the hospital. She reported that she keeps a spreadsheet documenting only the resident ' s name, where they were transferred to/from, date of transfer, reason for transfer, and the name of the facility staff liaison. In interview on 1/18/17, when asked if the facility evaluated Resident #1 ' s need for a secure unit, the Admissions Coordinator inaccurately reported that nothing in the hospital record stated they needed a locked unit. Thus, although the hospital documented that resident #1 required placement on a secure unit, no clinical staff were made aware, nor questioned, nor evaluated if the placement to this facility which has no secure unit was safe and appropriate for this resident. The three day qualifying hospital stay (qualifies resident for Medicare benefit) had been from 10/7/16 through 10/10/16. After the qualifying stay, Resident #1 was admitted to an open unit in the facility on 10/10/16. The physician order to admit to the nursing home was entered into the nursing home medical record on 10/10/16 at 9:02 PM. Review of the nursing home admission agreement revealed that it was never signed to evidence consent by the resident ' s son for the resident ' s care and treatment in the facility. Although with no secure unit the facility could not meet the known needs of Resident #1, the risks and benefits of placing the Resident in this facility were never discussed with the decision-maker for Resident #1, and the responsible party never consented to admission. In interview on 1/18/17, the Administrator reported (and provided documentation showing) that staff was unable to reach the responsible party (RP) and stated that was why the agreement was never signed. The single page document indicated that a Social Services Assistant had called the RP on 10/11/16 and left a voice message. The document then indicated that no attempts to call were made on 10/12/16 because the resident was out of the facility (at the hospital for evaluation after a fall). Next, the document revealed that on 10/14/16 the staff called and spoke with the RP and documented RP may stop by this weekend but if not the RP will need the admission packet mailed out. No verbal request for consent was ever documented including during this call, and no further attempts to get the agreement signed were found documented in the medical record. Although the Administrator reported that the admission agreement was never signed because they could not reach the RP, review of the medical record on 1/18/17 revealed that facility staff was able to reach the resident ' s son at 8:20 PM on 10/11/16 when staff provided notice to the guardian that the resident had suffered a fall. Review of the medical record also revealed that facility staff documented they were able to reach the resident ' s son a second time at 1:30 PM on 10/12/16 when results of a scan had been obtained and results were reported to the RP. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a third time at 4:16 PM on 10/12/16 when staff provided notice that the resident had been sent to the hospital for evaluation of the symptoms/concerns related to the fall the prior day. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a fourth time at 3:30 PM on 10/16/16 when staff provided notice that the resident had new orders prescribed. Nonetheless, staff reported that the consent for the admission was never obtained because staff could never reach the resident ' s son. 2. The facility failed to ensure staff documented and reported an elopement attempt when resident #1 was able to get out of the building, failed to conduct any investigation of the elopement attempt, and failed to immediately ensure the building was secure after the elopement attempt. On 10/11/16 at 3:24 PM Resident #1 was assessed at risk for elopement and use of a WanderGuard system was implemented. Per staff interviews with the Social Services Manager, Discharge Planner, and QA Director (all on 1/18/17) the resident at some point got out of the building despite the use of the WanderGuard system. The event was never documented by any staff and no-one interviewed could recall exactly when the event occurred. In interview on 1/18/17 at 9:20 AM, the Discharge Planner and Social Services Manager reported they were working when Resident #1 left the building and went across the parking lot and passed the neighboring [MEDICAL TREATMENT] building. They reported that many staff members were involved in bringing him/her back inside and calming him/her down, including the Administrator, physical therapy staff and multiple nurses. The discharge planner stated that after they got the resident back into the building, she got him/her a soft drink which he/she likes and that helped calm him/her down. Despite the occurrence of an elopement attempt where the resident got completely out of the building requiring many staff to get him/her back, review of the medical record on 1/18/17 revealed that no concurrent review note was opened to ensure review of facility processes and follow up for the resident ' s needs, no nursing notes documented the event, and the resident care plan was not updated following the event where he/she was able to leave the building despite use of the WanderGuard system. In addition to failing to document the event in a concurrent review to ensure opening a prompt review and investigation, in interview on 1/18/17, the facility QA nurse acknowledged that there had been no investigation of the event. 3. The facility failed to provide any discharge planning services for Resident #1. Review of the medical record revealed that no discharge planning services were provided as required, as no discharge planning notes were entered through the resident ' s entire admission. The only discharge note in the medical record was entered after discharge on 10/20/16 at 10:21 AM. This note documented, discharged : Resident was discharged on [DATE] to NMS Hagerstown. After searching with electronic record access during 12:45 interview on 1/18/17, the Director of Nursing corroborated that there were no discharge planning notes in the medical record for Resident #1. In interview with discharge planning staff #1 at 9:20 AM on 1/18/17, she reported that (former) staff #2 was assigned to Resident #2 for discharge planning. In interview by telephone at 5:00 PM on 1/18/17, former staff #2 stated that he wasn ' t assigned to provide discharge planning for resident #1 and he didn ' t know who was. 4. With no documented rationale at the time of discharge, no discharge planning, no discharge order, and no consent, facility staff discharged Resident #1and drove him/her to another facility in a distant county that also did not have the capability to meet his/her needs. A 10/19/17 note in the nursing section of the medical record revealed that the transfer was not urgent as Resident #1 was stable at the time of the discharge. This note documented that Resident #1 was calm and cooperative with care, no behavioral issues noted. Safety and falls precautions (were) maintained during transport. Further, the resident was noted as alert and verbally responsive, appears in no distress. Breathing even and unlabored, lung sounds clear bilaterally upon auscultation. Abdomen soft and non-tender, bowel sounds present in all quadrants. Skin warm and dry to touch. On 10/19/16 with no clinical review, with no order, with no consent, with insufficient discharge preparation to ensure the next facility could meet the resident ' s needs (where he/she needed the secure unit), and with evidence of no discharge planning having ever been provided, on 10/19/17 staff transferred Resident #1 to another sister-facility (same corporate ownership). The rationale for the decision to transfer the resident was not documented by any staff, anywhere in the medical record prior to the discharge. Review of the record revealed that on the following day, the physician entered a discharge note at 10:48 AM on 10/20/16 (after the discharge) indicating that the resident had to be discharged to another facility as (he/she) requires closed unit. A nursing discharge note entered at 4:38 PM on 10/19/17, documented that the resident was discharged and the time of discharge was 4:00 PM. The note continued that the resident was discharged by car with NH staff and stated the reason for the discharge was for admission. The note documented that the Physician and/or RP notified in standard text, and added in narrative that the physician was notified but that the responsible party actually was not reached and therefore was not notified and consent to move the resident was not obtained. Although staff documented the physician was notified at the time of the discharge, review of the medical record revealed that there was no physician order allowing staff to discharge the resident at the time that staff drove the resident to the next nursing home. A physician order was not entered into the medical record until 6:42 PM on 10/19/16 (nearly three hours after staff drove the resident from the nursing home). On 1/18/17, when surveyors requested to interview the staff that drove Resident #1 from the nursing home, the Administrator was also unable to determine just what staff it might have been that drove the resident from the facility on 10/19/17. This was also not documented. In interview with staff at the next facility where resident #1 was driven on 10/19/16, the staff stated that she called the RP after Resident #1 had arrived. The staff member said that the resident ' s son was angry and said that he had not been told his parent was being transferred. With no order, no notice, no consent, and no documented rationale, unqualified staff working outside their allowed scope of practice drove Resident #1 to another facility nearly 70 miles further away from the family. (Staff cannot assess and decide to discharge a resident with no physician documented rationale and with no physician order.) Review of the medical record on 1/18/16 revealed that on the day after discharge, on 10/20/16 at 10:48 AM the physician entered a discharge summary note that stated the discharge rationale was behavior was bothering other residents who are being at the rehab center for recovery; (he/she) had to be transferred to another facility to be in a closed unit. In interviews with the discharge planning staff on 1/18/17 at 9:20 and with the former social service assistant by phone on 1/19/17 at 5:00 PM, both corroborated that Resident #1 wandered and went in and out of other resident rooms which was intrusive. In interview on 1/26/17 at 10:45 AM with the Medical Director who was the attending for Resident #1, she corroborated that the reason for the discharge was that Resident #1 needed to be on a locked unit. Review of the medical record on 1/18/16 revealed that at the time of discharge, facility staff also failed to conduct sufficient discharge preparation as required to ensure the resident was actually going to a bed on a secure unit. Although not documented until after the discharge, the explicit reason for the transfer was the need for the resident to be on a secure unit for safety. However, with no discharge planning evidenced in the record at all, staff took resident #1 by car to the next location where a bed on the secure unit was actually not available. 4. Review of the medical record revealed that Resident# 2 was admitted to the facility in July 2016 for rehabilitation and possible long-term care. On 8/11/16 the Nurse Practitioner noted the resident had impaired judgment and on 8/30/16 the physician reported the resident was evaluated for capacity. The physician noted that Resident #2 lacked capacity to make decisions and had poor understanding of the choices he/she makes. Review of a complaint (MD 035) on 1/18/17 revealed an allegation that the facility staff transferred Resident #2 to the hospital for evaluation of an acute condition and then refused to accept the resident back to the nursing home because the resident owed the facility money. This concern was substantiated. Review of the medical record revealed that on 8/11/16 the resident was issued a 30 day notice of pending involuntary discharge. Although the practice is noncompliant, by policy the facility issues these notices preemptively when the facility believes there may be refusal by residents or their family members to pay for services in advance after the Medicare benefit period expires. The facility Notice of Involuntary Discharge Policy last revised 12/1/13 directs that it is the policy of (NMS) that 30 days prior to the last covered day of service, where payment has not been made in advance (and third-party coverage is ending), a resident will receive notice of intent to involuntarily discharge the resident. Review of the nursing home medical record revealed that Resident #2 was sent to the hospital on [DATE] and consistent with regulatory requirements, the facility documented in the medical record that the resident was expected to return to the facility. A hospital progress note dated 11/2/16 reported the resident was cleared for discharge backed to the nursing home on 10/29/16. However, on 10/29/16 at 13:12 the hospital case manager documented that he/she contacted the nursing home regarding the resident ' s return and was told the bed was no longer available. The case manager further noted that facility staff advised the resident had an outstanding balance and blamed the family for not cooperating with applying for Medicaid. However, review of the nursing home record revealed that the nursing home had not provided sufficient discharge planning assistance to the family. On 10/31/16 the hospital case manager was notified that the resident was by then ready for discharge. Upon contacting the facility's liaison the case manager was told the resident would not be able to return to the facility due to the outstanding balance. Review of hospital case management notes revealed that after the nursing home transferred the resident to the hospital and refused to accept the resident back, the hospital social service staff provided the discharge planning services which the nursing home had not. Hospital social service staff assisted the resident's responsible party to obtain power of attorney designation to be able to access the resident' s financial accounts. With nursing home policy in place to demand advance payment, the hospital record documented in an 11/2/16 note that the RP had sent a check to the facility and the facility still refused to accept the resident back until they received the check and could verify that it was the amount (he/she) owes. Another hospital progress note dated 11/16/16 reported the resident was still stable for discharge and that the nursing home was still refusing to readmit the resident indicating that they had not received documents needed to apply for Medicaid. Working with families of nursing home residents on the Medicaid application process is however the responsibility of the nursing home. An 11/18/16 hospital social services note indicated that the hospital social services staff was able to secure level of care (approval) for Maryland Medicaid funding for Resident #2. Hospital social service staff then was able to secure a secondary payer to satisfy the nursing home demand that payment be secured before accepting the resident back. On 12/7/16, when the facility was notified that the hospital had arranged for insurance authorization, the Administrator still refused to accept the resident back and demanded to have a meeting with the son first. The hospital record documented CM explained patient needs to go if (the authorization) is obtained and they still insisted on meeting the son and CM. Hospital social service staff coordinated filing the application for Maryland Medicaid which the resident did qualify for. The resident was then sent to another nursing home after the hospital provided all of the discharge planning services necessary to meet the needs of Resident #2. During an interview with the Staff #1 on 1/17/17 at 10:05, he/she was asked why the resident was not accepted for readmission. Staff #1 stated the facility attempted to assist the resident ' s family member in completing an application for Medicaid so that the resident could continue his/her stay at the facility, but the family member did not cooperate. No documented evidence supported this was accurate and the family member in fact cooperated fully when offered discharge planning assistance in the hospital. In interview with the surveyor on 1/17/17 at 11:25 AM, the Administrator stated there was a meeting at the hospital to discuss the application for Long-Term Care Medical Assistance. The meeting was attended by the Administrator, the facility ' s attorney, a hospital social worker and case manager. The Administrator stated they discussed how much money the resident owed the nursing home and that during the 6 weeks the resident was in the hospital they tried to get the documents from the family member and tried to work with the hospital. This was inaccurate. The nursing home sent the resident to the hospital, refused to accept the resident back, and did not assist in provision of discharge planning services that the hospital provided including obtaining the needed paperwork for the Resident to qualify for Maryland Medicaid. During an interview with surveyor #2 on 1/19/17 at 10:45, the hospital social worker reported he/she assisted the family member with getting Power of Attorney in order to access the resident' s account. The hospital social work staff also indicated that the RP sent 2 checks to the facility towards the resident ' s outstanding balance but the facility still declined to readmit the resident. The facility preemptively issued notice of involuntary discharge on 8/11/16 in violation of regulatory standards, and then involuntarily discharged the resident to a hospital emergency room while documenting in the medical record it was a discharge for which they anticipated resident return. Documenting that this was an appropriate discharge with return expected was inaccurate as the facility later acknowledged to the hospital that consistent with the noncompliant facility policies for involuntary discharges, there was no intention to accept Resident #2 back. Resident #2 remained in a hospital bed for 30 days while the hospital provided the family the needed discharge planning services that the nursing home had failed to provide, while the nursing home repeatedly refused to accept the resident back.

Based on interviews with staff and review of medical record and other pertinent documentation, the facility violated resident rights when the facility failed to obtain a written, signed admission agreement at or on admission, that ensured the resident and/or responsible party were aware of the rights, rules and regulations governing resident conduct and reposnsibilities during the stay; and then with no agreement in place, the facilty employed noncompliant systems for admissions, discharges and provision of care . The implementation of these noncompliant facility systems resulted in all of the following. (1) Without clinical review by qualified staff, with no oversight or order from the physician, and with no notification or consent from the responsible family, non-clinical facility staff admitted a cognitively impaired resident (Resident #1) for whom the facility did not have capability to meet his/her known clinical needs. (2) The facility failed to ensure that the responsible party was able to participate in decisions about care for Resident #1, when the resident was admitted , was readmitted and then was discharged over a nine day period without ever obtaining any consent. (3) The facility failed to provide any discharge planning services for Resident #1 through any consultation with the responsible party. (4) With no discharge planning, no discharge order, no notice or consent from the responsible party, and woefully insufficient preparation, facility staff acting outside allowed scope of practice, then discharged Resident #1 by driving him/her to another facility in a distant county that also did not have the capability to meet his/her needs; and (5) The facility implemented and enforced noncompliant policy to involuntarily discharge residents for alleged but nonexistent nonpayment when residents did not pay the facility for services in advance. (6) Without providing necessary discharge planning services, the facility issued a notice of intent to involuntarily discharge Resident #2 on 8/11/16, and then on 10/26/16 inappropriately discharged Resident #2 to a local hospital emergency department by sending him/her and then refusing to accept the resident back for payment related concerns. These interrelated concerns were evident for 2/16 residents reviewed during survey. The rights violations associated with noncompliant admission and discharge practices affecting Resident #1 resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:20 PM on 1/18/17; and the facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 11:49 PM on 1/18/17 while surveyors remained onsite. The plan included: - The facility conducted an immediate audit of all residents at risk for elopement to ensure that appropriate interventions were in place. - WanderGuard systems and locking door mechanisms are to be checked weekly. - Admissions staff were educated on consent requirements and on admission criteria. - A process was instituted where the Administrator will ensure consents are obtained before admissions. - Discharge planning staff were educated on consent, need to obtain bed availability in writing when resident is discharging, and need to start discharge planning process on admission. - Physicians will be reeducated on importance of providing discharge orders timely. - All staff to be reeducated on policy that elopement and elopement attempts must be documented in the medical record. DON will review elopement attempts and/or events in the facility morning meetings. - Discharge planning notes will be reviewed in morning meeting for any resident to be discharged to ensure discharge is planned and safe. - Administrator will now also review each discharge prior to discharge to ensure acceptance of resident at next provider of care as applicable. - The DON will audit three discharges per week to determine if policies are followed and audits will be reported into the facility QA Committee for oversight. The survey findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident ' s needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions/items. Each triggered care area must then be assessed in order to determine if care planning is needed; and if so to drive an effective plan that will ensure the assessed needs of each resident are met when care is delivered. 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. All staff must review and understand the plan so that care is delivered in a consistent manner across all days, shifts and disciplines. Resident dumping is the act of discharging a resident for reasons not allowed in regulation and often to inappropriate and unsafe locations. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. The Wander Guard management system incorporates a sensor that triggers an alarm when the sensor is detected by a monitoring device. Staff can ensure that vulnerable residents at risk for harm if they leave a facility building wear the sensor. The monitoring devices which detect the sensors are typically placed at potential exit locations so that staff will be alerted if residents wearing the sensor attempt to exit the building. 1. Without consent or clinical assessment, the facility admitted a cognitively impaired resident (Resident #1) for whom they did not have capability to meet the resident ' s known needs. Resident #1 did not have decision making capacity. Documentation from the hospital admission immediately prior to this nursing home admission indicated that the hospital assisted in obtaining guardianship for the resident ' s son and hospital record documentation revealed that the resident ' s son was the resident ' s Responsible Party (RP). Soon after admission to the nursing home, two physicians corroborated in a formal certification that resident #1 did not have decision-making capacity and both physicians signed the certification on 10/11/16. Hospital documentation sent to the facility for review in making the decision for the possible admission, revealed multiple hospital care planning notes (including notes entered on 10/7/16, 10/8/16, 10/9/16, and 10/10/16) documenting that Resident #1 had intermittent agitation and hallucinations, and that he/she needs to go to facility with (a) dementia unit . Observation of the nursing home on 1/18/17 and interview with the Director of Nursing at 12:45 on 1/18/17 revealed that this facility does not have a secure (locked) unit. In interview with the Administrator on 1/18/17, he reported that the Admissions Coordinator has a degree in Business Administration and is not clinical. In interview on 1/18/17 at 10:00 AM, the Admissions Coordinator stated that she with assistance from the Administrator (a physical therapist with additional training in health care administration) decides who is and who is not admitted . She stated that only when she has a clinical concern that she can ' t figure out does she consult with the Director of Nursing (DON). In interview with the Director of Nursing at 12:45 PM on 1/18/17, she also corroborated that the Admissions Coordinator and Administrator determine who can and cannot be admitted and that she (the DON) only gets involved if they bring a concern to her. Compounding the concern with admission decisions having been delegated to a non-clinical coordinator with no clinical or medical oversight, in interview on 1/26/17 at 10:14 AM, the Admissions Manager stated that she does not keep any notes regarding communication with hospitals seeking placement for patients discharging from the hospital. She reported that she keeps a spreadsheet documenting only the resident ' s name, where they were transferred to/from, date of transfer, reason for transfer, and the name of the facility staff liaison. In interview on 1/18/17, when asked if the facility evaluated Resident #1's need for a secure unit, the Admissions Coordinator inaccurately reported that nothing in the hospital record stated they needed a locked unit. Thus, although the hospital documented that resident #1 required placement on a secure unit, no clinical staff were made aware, nor questioned, nor evaluated if the placement to this facility which has no secure unit was safe and appropriate for this resident. The three day qualifying hospital stay (qualifies resident for Medicare benefit) had been from 10/7/16 through 10/10/16. After the qualifying stay, Resident #1 was admitted to an open unit in the facility on 10/10/16. The physician order to admit to the nursing home was entered into the nursing home medical record on 10/10/16 at 9:02 PM. Review of the nursing home admission agreement revealed that it was never signed to evidence consent by the resident ' s son for the resident ' s care and treatment in the facility. Although with no secure unit the facility could not meet the known needs of Resident #1, the risks and benefits of placing the Resident in this facility were never discussed with the decision-maker for Resident #1, and the responsible party never consented to admission. In interview on 1/18/17, the Administrator reported (and provided documentation showing) that staff was unable to reach the responsible party (RP) and stated that was why the agreement was never signed. The single page document indicated that a Social Services Assistant had called the RP on 10/11/16 and left a voice message. The document then indicated that no attempts to call were made on 10/12/16 because the resident was out of the facility (at the hospital for evaluation after a fall). Next, the document revealed that on 10/14/16 the staff called and spoke with the RP and documented RP may stop by this weekend but if not the RP will need the admission packet mailed out. No verbal request for consent was ever documented including during this call, and no further attempts to get the agreement signed were found documented in the medical record. Although the Administrator reported that the admission agreement was never signed because they could not reach the RP, review of the medical record on 1/18/17 revealed that facility staff was able to reach the resident ' s son at 8:20 PM on 10/11/16 when staff provided notice to the guardian that the resident had suffered a fall. Review of the medical record also revealed that facility staff documented they were able to reach the resident ' s son a second time at 1:30 PM on 10/12/16 when results of a scan had been obtained and results were reported to the RP. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a third time at 4:16 PM on 10/12/16 when staff provided notice that the resident had been sent to the hospital for evaluation of the symptoms/concerns related to the fall the prior day. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a fourth time at 3:30 PM on 10/16/16 when staff provided notice that the resident had new orders prescribed. Nonetheless, staff reported that the consent for the admission was never obtained because staff could never reach the resident ' s son. 2. The facility failed to ensure staff documented and reported an elopement attempt when resident #1 was able to get out of the building, failed to conduct any investigation of the elopement attempt, and failed to immediately ensure the building was secure after the elopement attempt. On 10/11/16 at 3:24 PM Resident #1 was assessed at risk for elopement and use of a WanderGuard system was implemented. Per staff interviews with the Social Services Manager, Discharge Planner, and QA Director (all on 1/18/17) the resident at some point got out of the building despite the use of the WanderGuard system. The event was never documented by any staff and no-one interviewed could recall exactly when the event occurred. In interview on 1/18/17 at 9:20 AM, the Discharge Planner and Social Services Manager reported they were working when Resident #1 left the building and went across the parking lot and passed the neighboring [MEDICAL TREATMENT] building. They reported that many staff members were involved in bringing him/her back inside and calming him/her down, including the Administrator, physical therapy staff and multiple nurses. The discharge planner stated that after they got the resident back into the building, she got him/her a soft drink which he/she likes and that helped calm him/her down. Despite the occurrence of an elopement attempt where the resident got completely out of the building requiring many staff to get him/her back, review of the medical record on 1/18/17 revealed that no concurrent review note was opened to ensure review of facility processes and follow up for the resident ' s needs, no nursing notes documented the event, and the resident care plan was not updated following the event where he/she was able to leave the building despite use of the WanderGuard system. In addition to failing to document the event in a concurrent review to ensure opening a prompt review and investigation, in interview on 1/18/17, the facility QA nurse acknowledged that there had been no investigation of the event. 3. The facility failed to provide any discharge planning services for Resident #1. Review of the medical record revealed that no discharge planning services were provided as required, as no discharge planning notes were entered through the resident ' s entire admission. The only discharge note in the medical record was entered after discharge on 10/20/16 at 10:21 AM. This note documented, discharged : Resident was discharged on [DATE] to NMS Hagerstown. After searching with electronic record access during 12:45 interview on 1/18/17, the Director of Nursing corroborated that there were no discharge planning notes in the medical record for Resident #1. In interview with discharge planning staff #1 at 9:20 AM on 1/18/17, she reported that (former) staff #2 was assigned to Resident #2 for discharge planning. In interview by telephone at 5:00 PM on 1/18/17, former staff #2 stated that he wasn ' t assigned to provide discharge planning for resident #1 and he didn ' t know who was. 4. With no documented rationale at the time of discharge, no discharge planning, no discharge order, and no consent, facility staff discharged Resident #1and drove him/her to another facility in a distant county that also did not have the capability to meet his/her needs. A 10/19/17 note in the nursing section of the medical record revealed that the transfer was not urgent as Resident #1 was stable at the time of the discharge. This note documented that Resident #1 was calm and cooperative with care, no behavioral issues noted. Safety and falls precautions (were) maintained during transport. Further, the resident was noted as alert and verbally responsive, appears in no distress. Breathing even and unlabored, lung sounds clear bilaterally upon auscultation. Abdomen soft and non-tender, bowel sounds present in all quadrants. Skin warm and dry to touch. On 10/19/16 with no clinical review, with no order, with no consent, with insufficient discharge preparation to ensure the next facility could meet the resident ' s needs (where he/she needed the secure unit), and with evidence of no discharge planning having ever been provided, on 10/19/17 staff transferred Resident #1 to another sister-facility (same corporate ownership). The rationale for the decision to transfer the resident was not documented by any staff, anywhere in the medical record prior to the discharge. Review of the record revealed that on the following day, the physician entered a discharge note at 10:48 AM on 10/20/16 (after the discharge) indicating that the resident had to be discharged to another facility as (he/she) requires closed unit. A nursing discharge note entered at 4:38 PM on 10/19/17, documented that the resident was discharged and the time of discharge was 4:00 PM. The note continued that the resident was discharged by car with NH staff and stated the reason for the discharge was for admission. The note documented that the Physician and/or RP notified in standard text, and added in narrative that the physician was notified but that the responsible party actually was not reached and therefore was not notified and consent to move the resident was not obtained. Although staff documented the physician was notified at the time of the discharge, review of the medical record revealed that there was no physician order allowing staff to discharge the resident at the time that staff drove the resident to the next nursing home. A physician order was not entered into the medical record until 6:42 PM on 1/19/16 (nearly three hours after staff drove the resident from the nursing home). On 1/18/17, when surveyors requested to interview the staff that drove Resident #1 from the nursing home, the Administrator was also unable to determine just what staff it might have been that drove the resident from the facility on 10/19/17. This was also not documented. In interview with staff at the next facility where resident #1 was driven on 10/19/16, the staff stated that she called the RP after Resident #1 had arrived. The staff member said that the resident ' s son was angry and said that he had not been told his parent was being transferred. With no order, no notice, no consent, and no documented rationale, unqualified staff working outside their allowed scope of practice drove Resident #1 to another facility nearly 70 miles further away from the family. (Staff cannot assess and decide to discharge a resident with no physician documented rationale and with no physician order.) Review of the medical record on 1/18/16 revealed that on the day after discharge, on 10/20/16 at 10:48 AM the physician entered a discharge summary note that stated the discharge rationale was behavior was bothering other residents who are being at the rehab center for recovery; (he/she) had to be transferred to another facility to be in a closed unit. In interviews with the discharge planning staff on 1/18/17 at 9:20 and with the former social service assistant by phone on 1/19/17 at 5:00 PM, both corroborated that Resident #1 wandered and went in and out of other resident rooms which was intrusive. In interview on 1/26/17 at 10:45 AM with the Medical Director who was the attending for Resident #1, she corroborated that the reason for the discharge was that Resident #1 needed to be on a locked unit. Review of the medical record on 1/18/16 revealed that at the time of discharge, facility staff also failed to conduct sufficient discharge preparation as required to ensure the resident was actually going to a bed on a secure unit. Although not documented until after the discharge, the explicit reason for the transfer was the need for the resident to be on a secure unit for safety. However, with no discharge planning evidenced in the record at all, staff took resident #1 by car to the next location where a bed on the secure unit was actually not available. 5. Review of facility policy on 1/18/17 revealed that by policy, in effect since 4/11/06 and last revised on 12/1/13, the facility has routinely issued inappropriate notices of intent to discharge residents in their care for non-payment when non-payment has actually not occurred. The facility policy specifically requires that the facility be paid in advance and if residents might not be able to pay in advance in the future when the prescribed 100 day Medicare coverage ends residents are immediately discharged . The regulations do not allow facilities to preemptively issue notice to evict a resident on the basis that they might not receive payment in advance when the Medicare coverage period ends. The facility Notice of Involuntary Discharge Policy documents that it is the policy of (NMS) that 30 days prior to the last covered day of service, where payment has not been made in advance (and third-party coverage is ending), a resident will receive notice of intent to involuntarily discharge the resident. Review of medical records revealed that with insufficient basis both Resident #5 and Resident #8 were issued notice of intent to involuntarily discharge based on nonpayment and both were then subsequently discharged . 6. Review of the medical record revealed that Resident# 2 was admitted to the facility in July 2016 for rehabilitation and possible long-term care. On 8/11/16 the Nurse Practitioner noted the resident had impaired judgment and on 8/30/16 the physician reported the resident was evaluated for capacity. The physician noted that Resident #2 lacked capacity to make decisions and had poor understanding of the choices he/she makes. Review of a complaint (MD 035) on 1/18/17 revealed an allegation that the facility staff transferred Resident #2 to the hospital for evaluation of an acute condition and then refused to accept the resident back to the nursing home because the resident owed the facility money. This concern was substantiated. Review of the medical record revealed that on 8/11/16 the resident was issued a 30 day notice of pending involuntary discharge. Although the practice is noncompliant, by policy the facility issues these notices preemptively when the facility believes there may be refusal by residents or their family members to pay for services in advance after the Medicare benefit period expires. The facility Notice of Involuntary Discharge Policy last revised 12/1/13 directs that it is the policy of (NMS) that 30 days prior to the last covered day of service, where payment has not been made in advance (and third-party coverage is ending), a resident will receive notice of intent to involuntarily discharge the resident. Review of the nursing home medical record revealed that Resident #2 was sent to the hospital on [DATE] and consistent with regulatory requirements, the facility documented in the medical record that the resident was expected to return to the facility. A hospital progress note dated 11/2/16 reported the resident was cleared for discharge backed to the nursing home on 10/29/16. However, on 10/29/16 at 13:12 the hospital case manager documented that he/she contacted the nursing home regarding the resident ' s return and was told the bed was no longer available. The case manager further noted that facility staff advised the resident had an outstanding balance and blamed the family for not cooperating with applying for Medicaid. However, review of the nursing home record revealed that the nursing home had not provided sufficient discharge planning assistance to the family. On 10/31/16 the hospital case manager was notified that the resident was by then ready for discharge. Upon contacting the facility ' s liaison the case manager was told the resident would not be able to return to the facility due to the outstanding balance. Review of hospital case management notes revealed that after the nursing home transferred the resident to the hospital and refused to accept the resident back, the hospital social service staff provided the discharge planning services which the nursing home had not. Hospital social service staff assisted the resident ' s responsible party to obtain power of attorney designation to be able to access the resident ' s financial accounts. With nursing home policy in place to demand advance payment, the hospital record documented in an 11/2/16 note that the RP had sent a check to the facility and the facility still refused to accept the resident back until they received the check and could verify that it was the amount (he/she) owes. Another hospital progress note dated 11/16/16 reported the resident was still stable for discharge and that the nursing home was still refusing to readmit the resident indicating that they had not received documents needed to apply for Medicaid. Working with families of nursing home residents on the Medicaid application process is however the responsibility of the nursing home. An 11/18/16 hospital social services note indicated that the hospital social services staff was able to secure level of care (approval) for Maryland Medicaid funding for Resident #2. Hospital social service staff then was able to secure a secondary payer to satisfy the nursing home demand that payment be secured before accepting the resident back. On 12/7/16, when the facility was notified that the hospital had arranged for insurance authorization, the Administrator still refused to accept the resident back and demanded to have a meeting with the son first. The hospital record documented, CM explained patient needs to go if (the authorization) is obtained and they still insisted on meeting the son and CM. Hospital social service staff coordinated filing the application for Maryland Medicaid which the resident did qualify for. The resident was then sent to another nursing home after the hospital provided all of the discharge planning services necessary to meet the needs of Resident #2. During an interview with the Staff #1 on 1/17/17 at 10:05 he/she was asked why the resident was not accepted for readmission. Staff #1 stated the facility attempted to assist the resident ' s family member in completing an application for Medicaid so that the resident could continue his/her stay at the facility, but the family member did not cooperate. No documented evidence supported this was accurate and the family member in fact cooperated fully when offered discharge planning assistance in the hospital. In interview with the surveyor on 1/17/17 at 11:25 AM the Administrator stated there was a meeting at the hospital to discuss the application for Long-Term Care Medical Assistance. The meeting was attended by the Administrator, the facility ' s attorney, a hospital social worker and case manager. The Administrator stated they discussed how much money the resident owed the nursing home and that during the 6 weeks the resident was in the hospital they tried to get the documents from the family member and tried to work with the hospital. This was inaccurate. The nursing home sent the resident to the hospital, refused to accept the resident back, and did not assist in provision of discharge planning services that the hospital provided including obtaining the needed paperwork for the Resident to qualify for Maryland Medicaid. During an interview with surveyor #2 on 1/19/17 at 10:45 the hospital social worker reported he/she assisted the family member with getting Power of Attorney in order to access the resident ' s account. The hospital social work staff also indicated that the RP sent 2 checks to the facility towards the resident ' s outstanding balance but the facility still declined to readmit the resident. The facility preemptively issued notice of involuntary discharge on 8/11/16 in violation of regulatory standards, and then involuntarily discharged the resident to a hospital emergency room while documenting in the medical record it was a discharge for which they anticipated resident return. Documenting that this was an appropriate discharge with return expected was inaccurate as the facility later acknowledged to the hospital that consistent with the noncompliant facility policies for involuntary discharges, there was no intention to accept Resident #2 back. Resident #2 remained in a hospital bed for 30 days while the hospital provided the family the needed discharge planning services that the nursing home had failed to provide, while the nursing home repeatedly refused to accept the resident back.

Based on interviews with staff and review of medical record and other pertinent documentation, the facility developed and implemented noncompliant systems for admissions, discharges and provision of care that resulted in violations of resident rights including the following. (1) The facility failed to notify or obtain consent from the Responsible Party (RP) for the 10/10/16 admission of a cognitively impaired resident when with review only by business admissions staff and no consideration or evaluation of the residents clinical, functional or psychosocial needs and no oversight or order from the physician, business admissions staff admitted Resident #1 into the facility that did not have capability to meet the resident ' s needs. (2) After discharge to the hospital for more than 24 hours, the facility readmitted Resident #1 on 10/13/16 with no order from the physician, with no documented notification to the RP, and with no consent from the RP. (3) With no discharge preparation, no discharge planning, no discharge order, and for the third time in 9 days no notice to or consent from the responsible party, facility staff discharged Resident #1 on 10/19/16 by driving him/her to another facility in a distant county that also did not have the capability to meet his/her needs; and (4) when Resident #1 attempted to elope form the facility the facility failed to document the event and failed to notify the RP. These interrelated concerns were evident for 1/16 residents reviewed during survey. Resident rights violations where residents were admitted , transferred and discharge without notice or consent and where the family was unaware even where their loved ones were, resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:20 PM on 1/18/17; and the facility developed a plan sufficient to remove immediacy, which was reviewed and accepted at 11:49 PM on 1/18/17 while surveyors remained onsite. The plan included: - The facility conducted an immediate audit of all residents at risk for elopement to ensure that appropriate interventions were in place. - WanderGuard systems and locking door mechanisms are to be checked weekly. - Admissions staff were educated on consent requirements and on admission criteria. - A process was instituted where the Administrator will ensure consents are obtained before admissions. - Discharge planning staff were educated on consent, need to obtain bed availability in writing when resident is discharging, and need to start discharge planning process on admission. - Physicians will be reeducated on importance of providing discharge orders timely. - All staff to be reeducated on policy that elopement and elopement attempts must be documented in the medical record. DON will review elopement attempts and/or events in the facility morning meetings. - Discharge planning notes will be reviewed in morning meeting for any resident to be discharged to ensure discharge is planned and safe. - Administrator will now also review each discharge prior to discharge to ensure acceptance of resident at next provider of care as applicable. - The DON will audit three discharges per week to determine if policies are followed and audits will be reported into the facility QA Committee for oversight. The survey findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident ' s needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions/items. Each triggered care area must then be assessed in order to determine if care planning is needed; and if so to drive an effective plan that will ensure the assessed needs of each resident are met when care is delivered. 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. All staff must review and understand the plan so that care is delivered in a consistent manner across all days, shifts and disciplines. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. The Wander Guard management system incorporates a sensor that triggers an alarm when the sensor is detected by a monitoring device. Staff can ensure that vulnerable residents at risk for harm if they leave a facility building wear the sensor. The monitoring devices, which detect the sensors, are typically placed at potential exit locations so that staff will be alerted if residents wearing the sensor attempt to exit the building. 1. Without consent or clinical assessment, the facility admitted a cognitively impaired resident (Resident #1) for whom they did not have capability to meet the resident ' s known needs. Resident #1 did not have decision making capacity. Documentation from the hospital admission immediately prior to this nursing home admission indicated that the hospital assisted in obtaining guardianship for the resident ' s son and hospital record documentation revealed that the resident ' s son was the resident ' s Responsible Party (RP). Soon after admission to the nursing home, two physicians corroborated in a formal certification that resident #1 did not have decision-making capacity and both physicians signed the certification on 10/11/16. Hospital documentation sent to the facility for review in making the decision for the possible admission, revealed multiple hospital care planning notes (including notes entered on 10/7/16, 10/8/16, 10/9/16, and 10/10/16) documenting that Resident #1 had intermittent agitation and hallucinations, and that he/she needs to go to facility with (a) dementia unit . Observation of the nursing home on 1/18/17 and interview with the Director of Nursing at 12:45 on 1/18/17 revealed that this facility does not have a secure (locked) unit. In interview with the Administrator on 1/18/17, he reported that the Admissions Coordinator has a degree in Business Administration and is not clinical. In interview on 1/18/17 at 10:00 AM, the Admissions Coordinator stated that she with assistance from the Administrator (a physical therapist with additional training in health care administration) decides who is and who is not admitted . She stated that only when she has a clinical concern that she can ' t figure out does she consult with the Director of Nursing (DON). In interview with the Director of Nursing at 12:45 PM on 1/18/17, she also corroborated that the Admissions Coordinator and Administrator determine who can and cannot be admitted and that she (the DON) only gets involved if they bring a concern to her. Compounding the concern with admission decisions having been delegated to a non-clinical coordinator with no clinical or medical oversight, in interview on 1/26/17 at 10:14 AM, the Admissions Manager stated that she does not keep any notes regarding communication with hospitals seeking placement for patients discharging from the hospital. She reported that she keeps a spreadsheet documenting only the resident ' s name, where they were transferred to/from, date of transfer, reason for transfer, and the name of the facility staff liaison. In interview on 1/18/17, when asked if the facility evaluated Resident #1 ' s need for a secure unit, the Admissions Coordinator inaccurately reported that nothing in the hospital record stated they needed a locked unit. Thus, although the hospital documented that resident #1 required placement on a secure unit, no clinical staff were made aware, nor questioned, nor evaluated if the placement to this facility which has no secure unit was safe and appropriate for this resident. The three day qualifying hospital stay (qualifies resident for Medicare benefit) had been from 10/7/16 through 10/10/16. After the qualifying stay, Resident #1 was admitted to an open unit in the facility on 10/10/16. The physician order [REDACTED]. Review of the nursing home admission agreement revealed that it was never signed to evidence consent by the resident ' s son for the resident ' s care and treatment in the facility. Although with no secure unit the facility could not meet the known needs of Resident #1, the risks and benefits of placing the Resident in this facility were never discussed with the decision-maker for Resident #1, and the responsible party never consented to admission. In interview on 1/18/17, the Administrator reported (and provided documentation showing) that staff was unable to reach the responsible party (RP) and stated that was why the agreement was never signed. The single page document indicated that a Social Services Assistant had called the RP on 10/11/16 and left a voice message. The document then indicated that no attempts to call were made on 10/12/16 because the resident was out of the facility (at the hospital for evaluation after a fall). Next, the document revealed that on 10/14/16 the staff called and spoke with the RP and documented RP may stop by this weekend but if not the RP will need the admission packet mailed out. No verbal request for consent was ever documented including during this call, and no further attempts to get the agreement signed were found documented in the medical record. Although the Administrator reported that the admission agreement was never signed because they could not reach the RP, review of the medical record on 1/18/17 revealed that facility staff was able to reach the resident ' s son at 8:20 PM on 10/11/16 when staff provided notice to the guardian that the resident had suffered a fall. Review of the medical record also revealed that facility staff documented they were able to reach the resident ' s son a second time at 1:30 PM on 10/12/16 when results of a scan had been obtained and results were reported to the RP. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a third time at 4:16 PM on 10/12/16 when staff provided notice that the resident had been sent to the hospital for evaluation of the symptoms/concerns related to the fall the prior day. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a fourth time at 3:30 PM on 10/16/16 when staff provided notice that the resident had new orders prescribed. Nonetheless, staff reported that the consent for the admission was never obtained because staff could never reach the resident ' s son. 2. After discharge to the hospital for more than 24 hours, with no order from the physician, with no documented notification to the RP, and still with no consent from the responsible party, facility staff again readmitted Resident #1 on 10/13/16. Review of the medical record revealed that Resident #1 suffered a fall in the facility on 10/11/16 at approximately 7:00 PM. On 10/12/16 Resident #1 was documented to have become lethargic and difficult to arouse. The physician was notified and Resident #1 was sent out to a local hospital for evaluation. Resident #1 left the facility to go to the hospital at 1:15 PM on 10/12/16. Review of the medical record revealed that resident #1 was out of the facility in the hospital for more than 24 hours. Resident #1 returned to the nursing facility on 10/13/16 at 2:15 PM. By regulatory definition when a resident is sent out to a hospital for more than 24 hours and then returns within 30 days, this is by definition a discharge and readmission. For this discharge, the facility was required to complete a Minimum Data Set (MDS) discharge assessment with an assessment reference date set to 10/12/16; and for the readmission the facility was required to complete an MDS re-entry record with an assessment reference date set to 10/13/16. Neither was found in the medical record or in the Federal database where completed MDS records are stored. Review of the medical record again revealed no documentation of notice to or of consent from the responsible party when the resident was readmitted on [DATE]. 3. With no discharge planning, no discharge order, and no consent facility staff discharged Resident #1 on 10/19/16 and drove him/her to another facility in a distant county nearly 70 miles away, that also did not have the capability to meet his/her needs. Review of the medical record revealed that with no evidence of any discharge planning or preparation for the resident and family, on 10/19/16 staff transferred Resident #1 to another sister-facility (same corporate ownership). Nursing notes indicated that the resident was stable when he/she left the facility driven by another staff member. In interview on 1/20/17 at 2:25 PM, staff at the next facility where resident #1 had been driven on 10/19/16 stated that she called the responsible party after Resident #1 had arrived. The staff member said that the resident ' s son was angry and said that he had not been told his parent was being transferred. Without notice or consent, his parent was moved nearly 70 miles further away from the family. In a consistent pattern of resident rights violations, the facility admitted Resident #1 without consent on 10/10/16, readmitted him/her still with no consent on 10/12/16, discharged him/her with no consent on 10/19/16, and with no preparation before the discharge failed to ensure the responsible party consented to admission in the next provider of care prior to the discharge from this location. These failures left family members at times, unaware even of where their loved ones were. 4. The facility failed to ensure staff documented and reported an elopement attempt when resident #1 was able to get out of the building, failed to conduct any investigation of the elopement attempt, failed to immediately ensure the building was secure after the elopement attempt, and never notified the RP of the event. On 10/11/16 at 3:24 PM Resident #1 was assessed at risk for elopement and use of a WanderGuard system was implemented. Per staff interviews with the Social Services Manager, Discharge Planner, and QA Director (all on 1/18/17) the resident at some point got out of the building despite the use of the WanderGuard system. The event was never documented by any staff and no-one interviewed could recall exactly when the event occurred. In interview on 1/18/17 at 9:20 AM, the Discharge Planner and Social Services Manager reported they were working when Resident #1 left the building and went across the parking lot and passed the neighboring [MEDICAL TREATMENT] building. They reported that many staff members were involved in bringing him/her back inside and calming him/her down, including the Administrator, physical therapy staff and multiple nurses. The discharge planner stated that after they got the resident back into the building, she got him/her a soft drink which he/she likes and that helped calm him/her down. Despite the occurrence of an elopement attempt where the resident got completely out of the building requiring many staff to get him/her back, review of the medical record on 1/18/17 revealed that no concurrent review note was opened to ensure review of facility processes and follow up for the resident ' s needs, no nursing notes documented the event, and the resident care plan was not updated following the event where he/she was able to leave the building despite use of the WanderGuard system. In addition to failing to document the event in a concurrent review to ensure opening a prompt review and investigation, in interview on 1/18/17, the facility QA nurse acknowledged that there had been no investigation of the event. Corroborating that there was no documentation of the event of of notice to the RP about the event, in interview with the RP at 11:45 AM on 1/30/17, the RP stated he was unaware that Resident #1 had gotten out of the building until question this morning by the Surveyor asking if he had been notified.

Based on staff interviews and review of medical record and other pertinent documentation the facility failed ensure an effective system for admissions and discharges when the facility (1) with insufficient assessment and without consent, admitted a resident without capacity (Resident #1) to the facility when the facility did not have the capability to meet his/her needs; (2) failed to provide any discharge planning services for Resident #1, including but not limited to sufficient preparation for discharge; and, (3) failed to provide a safe discharge when, with no discharge planning, no discharge order, no consent, and insufficient preparation, facility staff, acting outside allowed scope of practice, discharged Resident #1 and drove him/her to another facility in a distant county that also did not have the capability to meet his/her needs; and (4) the facility implemented and enforced noncompliant policy to involuntarily discharge residents for alleged but nonexistent nonpayment when residents did not pay the facility for services in advance. (5) The facility failed to ensure that staff members that admitted and discharged residents worked within allowed scope of practice. (6) Without providing necessary discharge planning services, the facility issued a notice of intent to involuntarily discharge Resident #2 on 8/11/16, and then on 10/26/16 inappropriately discharged Resident #2 to a local hospital emergency department by sending him/her and then refusing to accept the resident back for payment related concerns. These interrelated concerns were evident for 2/16 residents reviewed during survey. Unsafe admission and discharge practices where staff were empowered to work outside their allowed scope of practice resulted in resident rights violations when Resident #1 was admitted , readmitted and then discharged without any consent, without any physician order, and without documented rationale. Additionally, the facility enforced noncompliant discharge practices with current policy (in effect since 12/1/13) where inappropriate notices were issued and residents were promptly discharged when Medicare funding ended without regard for resident needs or safety. These noncompliant practices resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:20 PM on 1/18/17; and the facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 11:49 PM on 1/18/17 while surveyors remained onsite. The plan included: - The facility conducted an immediate audit of all residents at risk for elopement to ensure interventions were in place and appropriate. - WanderGuard systems and locking door mechanisms to be checked weekly. - Admissions staff were educated on consent requirements and admission criteria. New process was instituted where the Administrator will ensure consents are obtained before admissions. - Discharge planner was educated on consent, need to obtain bed availability in writing when resident is discharging, and need to start discharge planning process on admission. - Physicians will be reeducated on importance of providing discharge orders timely. - All staff to be reeducated on policy that elopement and elopement attempts must be documented in the medical record. DON will review elopement attempts and/or events in morning meeting. - Discharge planning note will be reviewed in morning meeting for any resident to be discharged to ensure discharge is planned and safe. - Administrator will now also review each discharge prior to discharge to ensure acceptance of resident at next provider of care as applicable. - The DON will audit three discharges per week to determine if policies are followed and audits will be reported into the facility QA Committee for oversight. The survey findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident ' s needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions/items. Each triggered care area must then be assessed in order to determine if care planning is needed; and if so to drive an effective plan that will ensure the assessed needs of each resident are met when care is delivered. 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. All staff must review and understand the plan so that care is delivered in a consistent manner across all days, shifts and disciplines. Resident dumping is the act of discharging a resident for reasons not allowed in regulation and often to inappropriate and unsafe locations. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. The Wander Guard management system incorporates a sensor that triggers an alarm when the sensor is detected by a monitoring device. Staff can ensure that vulnerable residents at risk for harm if they leave a facility building wear the sensor. The monitoring devices which detect the sensors are typically placed at potential exit locations so that staff will be alerted if residents wearing the sensor attempt to exit the building. 1. Without consent or clinical assessment, the facility admitted a cognitively impaired resident (Resident #1) for whom they did not have capability to meet the resident ' s known needs. Resident #1 did not have decision making capacity. Documentation from the hospital admission immediately prior to this nursing home admission indicated that the hospital assisted in obtaining guardianship for the resident ' s son and hospital record documentation revealed that the resident ' s son was the resident ' s Responsible Party (RP). Soon after admission to the nursing home, two physicians corroborated in a formal certification that resident #1 did not have decision-making capacity and both physicians signed the certification on 10/11/16. Hospital documentation sent to the facility for review in making the decision for the possible admission, revealed multiple hospital care planning notes (including notes entered on 10/7/16, 10/8/16, 10/9/16, and 10/10/16) documenting that Resident #1 had intermittent agitation and hallucinations, and that he/she needs to go to facility with (a) dementia unit . Observation of the nursing home on 1/18/17 and interview with the Director of Nursing at 12:45 on 1/18/17 revealed that this facility does not have a secure (locked) unit. In interview with the Administrator on 1/18/17, he reported that the Admissions Coordinator has a degree in Business Administration and is not clinical. In interview on 1/18/17 at 10:00 AM, the Admissions Coordinator stated that she with assistance from the Administrator (a physical therapist with additional training in health care administration) decides who is and who is not admitted . She stated that only when she has a clinical concern that she can ' t figure out does she consult with the Director of Nursing (DON). In interview with the Director of Nursing at 12:45 PM on 1/18/17, she also corroborated that the Admissions Coordinator and Administrator determine who can and cannot be admitted and that she (the DON) only gets involved if they bring a concern to her. Compounding the concern with admission decisions having been delegated to a non-clinical coordinator with no clinical or medical oversight, in interview on 1/26/17 at 10:14 AM, the Admissions Manager stated that she does not keep any notes regarding communication with hospitals seeking placement for patients discharging from the hospital. She reported that she keeps a spreadsheet documenting only the resident ' s name, where they were transferred to/from, date of transfer, reason for transfer, and the name of the facility staff liaison. In interview on 1/18/17, when asked if the facility evaluated Resident #1 ' s need for a secure unit, the Admissions Coordinator inaccurately reported that nothing in the hospital record stated they needed a locked unit. Thus, although the hospital documented that resident #1 required placement on a secure unit, no clinical staff were made aware, nor questioned, nor evaluated if the placement to this facility which has no secure unit was safe and appropriate for this resident. The three day qualifying hospital stay (qualifies resident for Medicare benefit) had been from 10/7/16 through 10/10/16. After the qualifying stay, Resident #1 was admitted to an open unit in the facility on 10/10/16. The physician order to admit to the nursing home was entered into the nursing home medical record on 10/10/16 at 9:02 PM. Review of the nursing home admission agreement revealed that it was never signed to evidence consent by the resident ' s son for the resident ' s care and treatment in the facility. Although with no secure unit the facility could not meet the known needs of Resident #1, the risks and benefits of placing the Resident in this facility were never discussed with the decision-maker for Resident #1, and the responsible party never consented to admission. In interview on 1/18/17, the Administrator reported (and provided documentation showing) that staff was unable to reach the responsible party (RP) and stated that was why the agreement was never signed. The single page document indicated that a Social Services Assistant had called the RP on 10/11/16 and left a voice message. The document then indicated that no attempts to call were made on 10/12/16 because the resident was out of the facility (at the hospital for evaluation after a fall). Next, the document revealed that on 10/14/16 the staff called and spoke with the RP and documented RP may stop by this weekend but if not the RP will need the admission packet mailed out. No verbal request for consent was ever documented including during this call, and no further attempts to get the agreement signed were found documented in the medical record. Although the Administrator reported that the admission agreement was never signed because they could not reach the RP, review of the medical record on 1/18/17 revealed that facility staff was able to reach the resident ' s son at 8:20 PM on 10/11/16 when staff provided notice to the guardian that the resident had suffered a fall. Review of the medical record also revealed that facility staff documented they were able to reach the resident ' s son a second time at 1:30 PM on 10/12/16 when results of a scan had been obtained and results were reported to the RP. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a third time at 4:16 PM on 10/12/16 when staff provided notice that the resident had been sent to the hospital for evaluation of the symptoms/concerns related to the fall the prior day. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a fourth time at 3:30 PM on 10/16/16 when staff provided notice that the resident had new orders prescribed. Nonetheless, staff reported that the consent for the admission was never obtained because staff could never reach the resident ' s son. 2. The facility failed to provide any discharge planning services for Resident #1. Review of the medical record revealed that no discharge planning services were provided as required, as no discharge planning notes were entered through the resident ' s entire admission. The only discharge note in the medical record was entered after discharge on 10/20/16 at 10:21 AM. This note documented, discharged : Resident was discharged on [DATE] to NMS Hagerstown. After searching with electronic record access during 12:45 interview on 1/18/17, the Director of Nursing corroborated that there were no discharge planning notes in the medical record for Resident #1. In interview with discharge planning staff #1 at 9:20 AM on 1/18/17, she reported that (former) staff #2 was assigned to Resident #2 for discharge planning. In interview by telephone at 5:00 PM on 1/18/17, former staff #2 stated that he wasn ' t assigned to provide discharge planning for resident #1 and he didn ' t know who was. 3. With no documented rationale at the time of discharge, no discharge planning, no discharge order, and no consent, facility staff discharged Resident #1and drove him/her to another facility in a distant county that also did not have the capability to meet his/her needs. A 10/19/17 note in the nursing section of the medical record revealed that the transfer was not urgent as Resident #1 was stable at the time of the discharge. This note documented that Resident #1 was calm and cooperative with care, no behavioral issues noted. Safety and falls precautions (were) maintained during transport. Further, the resident was noted as alert and verbally responsive, appears in no distress. Breathing even and unlabored, lung sounds clear bilaterally upon auscultation. Abdomen soft and non-tender, bowel sounds present in all quadrants. Skin warm and dry to touch. On 10/19/16 with no clinical review, with no order, with no consent, with insufficient discharge preparation to ensure the next facility could meet the resident ' s needs (where he/she needed the secure unit), and with evidence of no discharge planning having ever been provided, on 10/19/17 staff transferred Resident #1 to another sister-facility (same corporate ownership). The rationale for the decision to transfer the resident was not documented by any staff, anywhere in the medical record prior to the discharge. Review of the record revealed that on the following day, the physician entered a discharge note at 10:48 AM on 10/20/16 (after the discharge) indicating that the resident had to be discharged to another facility as (he/she) requires closed unit. A nursing discharge note entered at 4:38 PM on 10/19/17, documented that the resident was discharged and the time of discharge was 4:00 PM. The note continued that the resident was discharged by car with NH staff and stated the reason for the discharge was for admission. The note documented that the Physician and/or RP notified in standard text, and added in narrative that the physician was notified but that the responsible party actually was not reached and therefore was not notified and consent to move the resident was not obtained. Although staff documented the physician was notified at the time of the discharge, review of the medical record revealed that there was no physician order allowing staff to discharge the resident at the time that staff drove the resident to the next nursing home. A physician order was not entered into the medical record until 6:42 PM on 1/19/16 (nearly three hours after staff drove the resident from the nursing home). On 1/18/17, when surveyors requested to interview the staff that drove Resident #1 from the nursing home, the Administrator was also unable to determine just what staff it might have been that drove the resident from the facility on 10/19/17. This was also not documented. In interview with staff at the next facility where resident #1 was driven on 10/19/16, the staff stated that she called the RP after Resident #1 had arrived. The staff member said that the resident ' s son was angry and said that he had not been told his parent was being transferred. With no order, no notice, no consent, and no documented rationale, unqualified staff working outside their allowed scope of practice drove Resident #1 to another facility nearly 70 miles further away from the family. (Staff cannot assess and decide to discharge a resident with no physician documented rationale and with no physician order.) Review of the medical record on 1/18/16 revealed that on the day after discharge, on 10/20/16 at 10:48 AM the physician entered a discharge summary note that stated the discharge rationale was behavior was bothering other residents who are being at the rehab center for recovery; (he/she) had to be transferred to another facility to be in a closed unit. In interviews with the discharge planning staff on 1/18/17 at 9:20 and with the former social service assistant by phone on 1/19/17 at 5:00 PM, both corroborated that Resident #1 wandered and went in and out of other resident rooms which was intrusive. In interview on 1/26/17 at 10:45 AM with the Medical Director who was the attending for Resident #1, she corroborated that the reason for the discharge was that Resident #1 needed to be on a locked unit. Review of the medical record on 1/18/16 revealed that at the time of discharge, facility staff also failed to conduct sufficient discharge preparation as required to ensure the resident was actually going to a bed on a secure unit. Although not documented until after the discharge, the explicit reason for the transfer was the need for the resident to be on a secure unit for safety. However, with no discharge planning evidenced in the record at all, staff took resident #1 by car to the next location where a bed on the secure unit was actually not available. 4. Review of facility policy on 1/18/17 revealed that by policy, in effect since 4/11/06 and last revised on 12/1/13, the facility has routinely issued inappropriate notices of intent to discharge residents in their care for non-payment when non-payment has actually not occurred. The facility policy specifically requires that the facility be paid in advance and if residents might not be able to pay in advance in the future when the prescribed 100 day Medicare coverage ends residents are immediately discharged . The regulations do not allow facilities to preemptively issue notice to evict a resident on the basis that they might not receive payment in advance when the Medicare coverage period ends. The facility Notice of Involuntary Discharge Policy documents that it is the policy of (NMS) that 30 days prior to the last covered day of service, where payment has not been made in advance (and third-party coverage is ending), a resident will receive notice of intent to involuntarily discharge the resident. Review of medical records revealed that with insufficient basis both Resident #5 and Resident #8 were issued notice of intent to involuntarily discharge based on nonpayment and both were then subsequently discharged . Review of medical records revealed that with insufficient basis both Resident #5 and Resident #8 were issued notice of intent to involuntarily discharge based on nonpayment and both were then subsequently discharged . 5. The facility failed to ensure that facility staff acted only within their level of knowledge, skills, and scope of allowable practice. Review of the medical record revealed that more than four hours facility staff had already admitted Resident #1 on 10/10/16 at 4:45 PM without consent and without assessment of his/her clinical needs, the Medical Director gave staff the order for the admission on 10/10/16 at 9:02 PM. With no order in place, staff was acting beyond allowed scope of practice when they admitted Resident #1. Review of the medical record revealed that hours after facility staff drove Resident #1 from the facility at 4:00 PM on 10/19/16 without consent, planning or required preparation, the Medical Director gave staff an order for [REDACTED].#1. Review of the medical record revealed that on the day after facility staff drove Resident #1 from the facility without any planning, preparation or consent, on 10/20/16 at 10:48 AM the Medical Director entered documentation of a rationale for the discharge that facility staff did not have at the time they drove Resident #1 to another nursing home. With no documented rationale, staff was acting beyond allowed scope of practice when they discharged Resident #1. Last, review of facility policy noted above, explicitly codified that staff were to issue inappropriate and unsupported notices of intent to discharge based on unsupported allegations of nonpayment, and then enforced that staff discharge residents based on facility billing determinations without any consideration of resident safety and clinical needs. 6. Review of the medical record revealed that Resident# 2 was admitted to the facility in July 2016 for rehabilitation and possible long-term care. On 8/11/16 the Nurse Practitioner noted the resident had impaired judgment and on 8/30/16 the physician reported the resident was evaluated for capacity. The physician noted that Resident #2 lacked capacity to make decisions and had poor understanding of the choices he/she makes. Review of a complaint (MD 035) on 1/18/17 revealed an allegation that the facility staff transferred Resident #2 to the hospital for evaluation of an acute condition and then refused to accept the resident back to the nursing home because the resident owed the facility money. This concern was substantiated. Review of the medical record revealed that on 8/11/16 the resident was issued a 30 day notice of pending involuntary discharge. Although the practice is noncompliant, by policy the facility issues these notices preemptively when the facility believes there may be refusal by residents or their family members to pay for services in advance after the Medicare benefit period expires. The facility Notice of Involuntary Discharge Policy last revised 12/1/13 directs that it is the policy of (NMS) that 30 days prior to the last covered day of service, where payment has not been made in advance (and third-party coverage is ending), a resident will receive notice of intent to involuntarily discharge the resident. Review of the nursing home medical record revealed that Resident #2 was sent to the hospital on [DATE] and consistent with regulatory requirements, the facility documented in the medical record that the resident was expected to return to the facility. A hospital progress note dated 11/2/16 reported the resident was cleared for discharge backed to the nursing home on 10/29/16. However, on 10/29/16 at 13:12 the hospital case manager documented that he/she contacted the nursing home regarding the resident ' s return and was told the bed was no longer available. The case manager further noted that facility staff advised the resident had an outstanding balance and blamed the family for not cooperating with applying for Medicaid. However, review of the nursing home record revealed that the nursing home had not provided sufficient discharge planning assistance to the family. On 10/31/16 the hospital case manager was notified that the resident was by then ready for discharge. Upon contacting the facility ' s liaison the case manager was told the resident would not be able to return to the facility due to the outstanding balance. Review of hospital case management notes revealed that after the nursing home transferred the resident to the hospital and refused to accept the resident back, the hospital social service staff provided the discharge planning services which the nursing home had not. Hospital social service staff assisted the resident' s responsible party to obtain power of attorney designation to be able to access the resident ' s financial accounts. With nursing home policy in place to demand advance payment, the hospital record documented in an 11/2/16 note that the RP had sent a check to the facility and the facility still refused to accept the resident back until they received the check and could verify that it was the amount (he/she) owes. Another hospital progress note dated 11/16/16 reported the resident was still stable for discharge and that the nursing home was still refusing to readmit the resident indicating that they had not received documents needed to apply for Medicaid. Working with families of nursing home residents on the Medicaid application process is however the responsibility of the nursing home. An 11/18/16 hospital social services note indicated that the hospital social services staff was able to secure level of care (approval) for Maryland Medicaid funding for Resident #2. Hospital social service staff then was able to secure a secondary payer to satisfy the nursing home demand that payment be secured before accepting the resident back. On 12/7/16, when the facility was notified that the hospital had arranged for insurance authorization, the Administrator still refused to accept the resident back and demanded to have a meeting with the son first. The hospital record documented CM explained patient needs to go if (the authorization) is obtained and they still insisted on meeting the son and CM. Hospital social service staff coordinated filing the application for Maryland Medicaid which the resident did qualify for. The resident was then sent to another nursing home after the hospital provided all of the discharge planning services necessary to meet the needs of Resident #2. During an interview with the Staff #1 on 1/17/17 at 10:05 he/she was asked why the resident was not accepted for readmission. Staff #1 stated the facility attempted to assist the resident ' s family member in completing an application for Medicaid so that the resident could continue his/her stay at the facility, but the family member did not cooperate. No documented evidence supported this was accurate and the family member in fact cooperated fully when offered discharge planning assistance in the hospital. In interview with the surveyor on 1/17/17 at 11:25 AM the Administrator stated there was a meeting at the hospital to discuss the application for Long-Term Care Medical Assistance. The meeting was attended by the Administrator, the facility ' s attorney, a hospital social worker and case manager. The Administrator stated they discussed how much money the resident owed the nursing home and that during the 6 weeks the resident was in the hospital they tried to get the documents from the family member and tried to work with the hospital. This was inaccurate. The nursing home sent the resident to the hospital, refused to accept the resident back, and did not assist in provision of discharge planning services that the hospital provided including obtaining the needed paperwork for the Resident to qualify for Maryland Medicaid. During an interview with surveyor #2 on 1/19/17 at 10:45 the hospital social worker reported he/she assisted the family member with getting Power of Attorney in order to access the resident' s account. The hospital social work staff also indicated that the RP sent 2 checks to the facility towards the resident' s outstanding balance but the facility still declined to readmit the resident. The facility preemptively issued notice of involuntary discharge on 8/11/16 in violation of regulatory standards, and then involuntarily discharged the resident to a hospital emergency room while documenting in the medical record it was a discharge for which they anticipated resident return. Documenting that this was an appropriate discharge with return expected was inaccurate as the facility later acknowledged to the hospital that consistent with the noncompliant facility policies for involuntary discharges, there was no intention to accept Resident #2 back. Resident #2 remained in a hospital bed for 30 days while the hospital provided the family the needed discharge planning services that the nursing home had failed to provide, while the nursing home repeatedly refused to accept the resident back.

Based on interviews with staff and review of medical record and other pertinent documentation, the facility failed to ensure an effective post-discharge plan was developed prior to discharging residents. With no planning or preparation, resident #1 was discharge to another facility that could not meet his/her needs related to elopement risk and therefore the failure to plan and prepare for the discharge left Resident #1 at increased risk for elopement, harm and possible death. This concern was evident for 1/16 residents reviewed during survey. The rights violations associated with noncompliant admission and discharge practices resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:20 PM on 1/18/17; and the facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 11:49 PM on 1/18/17 while surveyors remained onsite. The plan included: - The facility conducted an immediate audit of all residents at risk for elopement to ensure that appropriate interventions were in place. - WanderGuard systems and locking door mechanisms are to be checked weekly. - Admissions staff were educated on consent requirements and on admission criteria. - A process was instituted where the Administrator will ensure consents are obtained before admissions. - Discharge planning staff were educated on consent, need to obtain bed availability in writing when resident is discharging, and need to start discharge planning process on admission. - Physicians will be reeducated on importance of providing discharge orders timely. - All staff to be reeducated on policy that elopement and elopement attempts must be documented in the medical record. DON will review elopement attempts and/or events in the facility morning meetings. - Discharge planning notes will be reviewed in morning meeting for any resident to be discharged to ensure discharge is planned and safe. - Administrator will now also review each discharge prior to discharge to ensure acceptance of resident at next provider of care as applicable. - The DON will audit three discharges per week to determine if policies are followed and audits will be reported into the facility QA Committee for oversight. The survey findings include: 1. The facility failed to provide any discharge planning services for Resident #1. Review of the medical record revealed that no discharge planning services were provided as required, as no discharge planning notes were entered through the resident ' s entire admission. The only discharge note in the medical record was entered after discharge on 10/20/16 at 10:21 AM. This note documented, discharged : Resident was discharged on [DATE] to NMS Hagerstown. After searching with electronic record access during 12:45 interview on 1/18/17, the Director of Nursing corroborated that there were no discharge planning notes in the medical record for Resident #1. In interview with discharge planning staff #1 at 9:20 AM on 1/18/17, she reported that (former) staff #2 was assigned to Resident #2 for discharge planning. In interview by telephone at 5:00 PM on 1/18/17, former staff #2 stated that he wasn ' t assigned to provide discharge planning for resident #1 and he didn ' t know who was. 2. With no documented rationale at the time of discharge, no discharge planning, no discharge order, and no consent, facility staff discharged Resident #1and drove him/her to another facility in a distant county that also did not have the capability to meet his/her needs. A 10/19/17 note in the nursing section of the medical record revealed that the transfer was not urgent as Resident #1 was stable at the time of the discharge. This note documented that Resident #1 was calm and cooperative with care, no behavioral issues noted. Safety and falls precautions (were) maintained during transport. Further, the resident was noted as alert and verbally responsive, appears in no distress. Breathing even and unlabored, lung sounds clear bilaterally upon auscultation. Abdomen soft and non-tender, bowel sounds present in all quadrants. Skin warm and dry to touch. On 10/19/16 with no clinical review, with no order, with no consent, with insufficient discharge preparation to ensure the next facility could meet the resident ' s needs (where he/she needed the secure unit), and with evidence of no discharge planning having ever been provided, on 10/19/17 staff transferred Resident #1 to another sister-facility (same corporate ownership). The rationale for the decision to transfer the resident was not documented by any staff, anywhere in the medical record prior to the discharge. Review of the record revealed that on the following day, the physician entered a discharge note at 10:48 AM on 10/20/16 (after the discharge) indicating that the resident had to be discharged to another facility as (he/she) requires closed unit. A nursing discharge note entered at 4:38 PM on 10/19/17, documented that the resident was discharged and the time of discharge was 4:00 PM. The note continued that the resident was discharged by car with NH staff and stated the reason for the discharge was for admission. The note documented that the Physician and/or RP notified in standard text, and added in narrative that the physician was notified but that the responsible party actually was not reached and therefore was not notified and consent to move the resident was not obtained. Although staff documented the physician was notified at the time of the discharge, review of the medical record revealed that there was no physician order allowing staff to discharge the resident at the time that staff drove the resident to the next nursing home. A physician order was not entered into the medical record until 6:42 PM on 1/19/16 (nearly three hours after staff drove the resident from the nursing home). On 1/18/17, when surveyors requested to interview the staff that drove Resident #1 from the nursing home, the Administrator was also unable to determine just what staff it might have been that drove the resident from the facility on 10/19/17. This was also not documented. In interview with staff at the next facility where resident #1 was driven on 10/19/16, the staff stated that she called the RP after Resident #1 had arrived. The staff member said that the resident ' s son was angry and said that he had not been told his parent was being transferred. With no order, no notice, no consent, and no documented rationale, unqualified staff working outside their allowed scope of practice drove Resident #1 to another facility nearly 70 miles further away from the family. (Staff cannot assess and decide to discharge a resident with no physician documented rationale and with no physician order.) Review of the medical record on 1/18/16 revealed that on the day after discharge, on 10/20/16 at 10:48 AM the physician entered a discharge summary note that stated the discharge rationale was behavior was bothering other residents who are being at the rehab center for recovery; (he/she) had to be transferred to another facility to be in a closed unit. In interviews with the discharge planning staff on 1/18/17 at 9:20 and with the former social service assistant by phone on 1/19/17 at 5:00 PM, both corroborated that Resident #1 wandered and went in and out of other resident rooms which was intrusive. In interview on 1/26/17 at 10:45 AM with the Medical Director who was the attending for Resident #1, she corroborated that the reason for the discharge was that Resident #1 needed to be on a locked unit. Review of the medical record on 1/18/16 revealed that at the time of discharge, facility staff also failed to conduct sufficient discharge preparation as required to ensure the resident was actually going to a bed on a secure unit. Although not documented until after the discharge, the explicit reason for the transfer was the need for the resident to be on a secure unit for safety. However, with no discharge planning evidenced in the record at all, staff took resident #1 by car to the next location where a bed on the secure unit was actually not available.

Based on interviews with staff and review of medical record and other pertinent documentation, the facility violated resident rights when admitting and discharging residents with no notice and with no consent. The implementation of these noncompliant facility systems resulted in all of the following. (1) Without clinical review by sufficiently qualified staff, with no oversight or order from the physician, and with no notification or consent from the responsible family, non-clinical facility staff admitted a cognitively impaired resident (Resident #1) for whom the facility did not have capability to meet his/her known clinical needs. (2) The facility failed to ensure that the responsible party was able to participate in decisions about care for Resident #1, when the facility admitted , readmitted and then discharged Resident #1 over a nine day period without ever obtaining any consent. (3) The facility failed to provide any discharge planning services for Resident #1 through any consultation with the responsible party. (4) With no discharge planning, no discharge order, no notice or consent from the responsible party, and woefully insufficient preparation, facility staff, acting outside their allowable scope of practice, discharged Resident #1 by driving him/her to another facility in a distant county that also did not have the capability to meet his/her needs. (5) The facility implemented and enforced noncompliant policy to involuntarily discharge residents for alleged but nonexistent nonpayment when residents did not pay the facility for services in advance. (6) Without providing necessary discharge planning services, the facility issued a notice of intent to involuntarily discharge Resident #2 on 8/11/16, and then on 10/26/16 inappropriately discharged Resident #2 to a local hospital emergency department by sending him/her and then refusing to accept the resident back for payment related concerns. These interrelated concerns were evident for 2/16 residents reviewed during survey. The noncompliant admission and discharge practices resulted in resident rights violations and in failure to meet the resident needs by accepting him/her into a facility that could not meet his/her known needs. The Maryland Office of Health Care Quality (OHCQ) determined therefore that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:20 PM on 1/18/17; and the facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 11:49 PM on 1/18/17 while surveyors remained onsite. The plan included: - The facility conducted an immediate audit of all residents at risk for elopement to ensure that appropriate interventions were in place. - Wander Guard systems and locking door mechanisms are to be checked weekly. - Admissions staff were educated on consent requirements and on admission criteria. - A process was instituted where the Administrator will ensure consents are obtained before admissions. - Discharge planning staff were educated on consent, the need to obtain bed availability in writing when resident is discharging, and the need to start discharge planning process on admission. - Physicians will be reeducated on importance of providing discharge orders timely. - All staff to be reeducated on policy that elopement and elopement attempts must be documented in the medical record. DON will review elopement attempts and/or events in the facility morning meetings. - Discharge planning notes will be reviewed in morning meeting for any resident to be discharged to ensure discharge is planned and safe. - Administrator will now also review each discharge prior to discharge to ensure acceptance of resident at next provider of care as applicable. - The DON will audit three discharges per week to determine if policies are followed and audits will be reported into the facility QA Committee for oversight. The survey findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident ' s needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions/items. Each triggered care area must then be assessed in order to determine if care planning is needed; and if so to drive an effective plan that will ensure the assessed needs of each resident are met when care is delivered. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, track and evaluate the effectiveness of the resident's care. All staff must review and understand the plan so that care is delivered in a consistent manner across all days, shifts and disciplines. Resident dumping is the act of discharging a resident for reasons not allowed in regulation and often to inappropriate and unsafe locations. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. The Wander Guard management system incorporates a sensor that triggers an alarm when the sensor is detected by a monitoring device. The monitoring devices which detect the sensors are typically placed at potential exit locations so that staff will be alerted if residents wearing the sensor attempt to exit the building. 1. Without consent or clinical assessment, the facility admitted a cognitively impaired resident (Resident #1) for whom they did not have capability to meet the resident ' s known needs. Resident #1 did not have decision making capacity. Documentation from the hospital admission immediately prior to this nursing home admission indicated that the hospital assisted in obtaining guardianship for the resident ' s son and hospital record documentation revealed that the resident ' s son was the resident ' s Responsible Party (RP). Soon after admission to the nursing home, two physicians corroborated in a formal certification that resident #1 did not have decision-making capacity and both physicians signed the certification on 10/11/16. Hospital documentation sent to the facility for review in making the decision for the possible admission, revealed multiple hospital care planning notes (including notes entered on 10/7/16, 10/8/16, 10/9/16, and 10/10/16) documenting that Resident #1 had intermittent agitation and hallucinations, and that he/she needs to go to facility with (a) dementia unit . Observation of the nursing home on 1/18/17 and interview with the Director of Nursing at 12:45 on 1/18/17 revealed that this facility does not have a secure (locked) unit. In interview with the Administrator on 1/18/17, he reported that the Admissions Coordinator has a degree in Business Administration and is not clinical. In interview on 1/18/17 at 10:00 AM, the Admissions Coordinator stated that she with assistance from the Administrator (a physical therapist with additional training in health care administration) decides who is and who is not admitted . She stated that only when she has a clinical concern that she can ' t figure out does she consult with the Director of Nursing (DON). In interview with the Director of Nursing at 12:45 PM on 1/18/17, she also corroborated that the Admissions Coordinator and Administrator determine who can and cannot be admitted and that she (the DON) only gets involved if they bring a concern to her. Compounding the concern with admission decisions having been delegated to a non-clinical coordinator with no clinical or medical oversight, in interview on 1/26/17 at 10:14 AM, the Admissions Manager stated that she does not keep any notes regarding communication with hospitals seeking placement for patients discharging from the hospital. She reported that she keeps a spreadsheet documenting only the resident ' s name, where they were transferred to/from, date of transfer, reason for transfer, and the name of the facility staff liaison. In interview on 1/18/17, when asked if the facility evaluated Resident #1 ' s need for a secure unit, the Admissions Coordinator inaccurately reported that nothing in the hospital record stated they needed a locked unit. Thus, although the hospital documented that resident #1 required placement on a secure unit, no clinical staff were made aware, nor questioned, nor evaluated if the placement to this facility which has no secure unit was safe and appropriate for this resident. The three day qualifying hospital stay (qualifies resident for Medicare benefit) had been from 10/7/16 through 10/10/16. After the qualifying stay, Resident #1 was admitted to an open unit in the facility on 10/10/16. The physician order to admit to the nursing home was entered into the nursing home medical record on 10/10/16 at 9:02 PM. Review of the nursing home admission agreement revealed that it was never signed to evidence consent by the resident ' s son for the resident ' s care and treatment in the facility. Although with no secure unit the facility could not meet the known needs of Resident #1, the risks and benefits of placing the Resident in this facility were never discussed with the decision-maker for Resident #1, and the responsible party never consented to admission. In interview on 1/18/17, the Administrator reported (and provided documentation showing) that staff was unable to reach the responsible party (RP) and stated that was why the agreement was never signed. The single page document indicated that a Social Services Assistant had called the RP on 10/11/16 and left a voice message. The document then indicated that no attempts to call were made on 10/12/16 because the resident was out of the facility (at the hospital for evaluation after a fall). Next, the document revealed that on 10/14/16 the staff called and spoke with the RP and documented RP may stop by this weekend but if not the RP will need the admission packet mailed out. No verbal request for consent was ever documented including during this call, and no further attempts to get the agreement signed were found documented in the medical record. Although the Administrator reported that the admission agreement was never signed because they could not reach the RP, review of the medical record on 1/18/17 revealed that facility staff was able to reach the resident ' s son at 8:20 PM on 10/11/16 when staff provided notice to the guardian that the resident had suffered a fall. Review of the medical record also revealed that facility staff documented they were able to reach the resident ' s son a second time at 1:30 PM on 10/12/16 when results of a scan had been obtained and results were reported to the RP. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a third time at 4:16 PM on 10/12/16 when staff provided notice that the resident had been sent to the hospital for evaluation of the symptoms/concerns related to the fall the prior day. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a fourth time at 3:30 PM on 10/16/16 when staff provided notice that the resident had new orders prescribed. Nonetheless, staff reported that the consent for the admission was never obtained because staff could never reach the resident ' s son. In telephone interview on 1/30/17 at 11:45 AM, the RP stated that he never heard from or spoke with anyone from the nursing home about anything; and he only learned about the fall from the hospital when hospital staff contacted him/her. 2. The facility failed to ensure staff documented and reported an elopement attempt when resident #1 was able to get out of the building, failed to conduct any investigation of the elopement attempt, failed to immediately ensure the building was secure after the elopement attempt, and never notified the RP of the event. On 10/11/16 at 3:24 PM Resident #1 was assessed at risk for elopement and use of a Wander Guard system was implemented. Per staff interviews with the Social Services Manager, Discharge Planner, and QA Director (all on 1/18/17) the resident at some point got out of the building despite the use of the Wander Guard system. The event was never documented by any staff and no-one interviewed could recall exactly when the event occurred. In interview on 1/18/17 at 9:20 AM, the Discharge Planner and Social Services Manager reported they were working when Resident #1 left the building and went across the parking lot and passed the neighboring [MEDICAL TREATMENT] building. They reported that many staff members were involved in bringing him/her back inside and calming him/her down, including the Administrator, physical therapy staff and multiple nurses. The discharge planner stated that after they got the resident back into the building, she got him/her a soft drink which he/she likes and that helped calm him/her down. Despite the occurrence of an elopement attempt where the resident got completely out of the building requiring many staff to get him/her back, review of the medical record on 1/18/17 revealed that no concurrent review note was opened to ensure review of facility processes and follow up for the resident ' s needs, no nursing notes documented the event, and the resident care plan was not updated following the event where he/she was able to leave the building despite use of the Wander Guard system. In addition to failing to document the event in a concurrent review to ensure opening a prompt review and investigation, in interview on 1/18/17, the facility QA nurse acknowledged that there had been no investigation of the event. Corroborating that there was no documentation of the event of of notice to the RP about the event, in interview with the RP at 11:45 AM on 1/30/17, the RP stated he was unaware that Resident #1 had gotten out of the building until question this morning by the Surveyor asking if he had been notified. 3. The facility failed to provide any discharge planning services for Resident #1. Review of the medical record revealed that no discharge planning services were provided as required, as no discharge planning notes were entered through the resident ' s entire admission. The only discharge note in the medical record was entered after discharge on 10/20/16 at 10:21 AM. This note documented, discharged : Resident was discharged on [DATE] to NMS Hagerstown. After searching with electronic record access during 12:45 interview on 1/18/17, the Director of Nursing corroborated that there were no discharge planning notes in the medical record for Resident #1. In interview with discharge planning staff #1 at 9:20 AM on 1/18/17, she reported that (former) staff #2 was assigned to Resident #2 for discharge planning. In interview by telephone at 5:00 PM on 1/18/17, former staff #2 stated that he wasn ' t assigned to provide discharge planning for resident #1 and he didn ' t know who was. 4. With no documented rationale at the time of discharge, no discharge planning, no discharge order, and no consent, facility staff discharged Resident #1 and drove him/her to another facility in a distant county that also did not have the capability to meet his/her needs. A 10/19/17 note in the nursing section of the medical record revealed that the transfer was not urgent as Resident #1 was stable at the time of the discharge. This note documented that Resident #1 was calm and cooperative with care, no behavioral issues noted. Safety and falls precautions (were) maintained during transport. Further, the resident was noted as alert and verbally responsive, appears in no distress. Breathing even and unlabored, lung sounds clear bilaterally upon auscultation. Abdomen soft and non-tender, bowel sounds present in all quadrants. Skin warm and dry to touch. On 10/19/16 with no clinical review, with no order, with no consent, with insufficient discharge preparation to ensure the next facility could meet the resident ' s needs (where he/she needed the secure unit), and with evidence of no discharge planning having ever been provided, on 10/19/17 staff transferred Resident #1 to another sister-facility (same corporate ownership). The rationale for the decision to transfer the resident was not documented by any staff, anywhere in the medical record prior to the discharge. Review of the record revealed that on the following day, the physician entered a discharge note at 10:48 AM on 10/20/16 (after the discharge) indicating that the resident had to be discharged to another facility as (he/she) requires closed unit. A nursing discharge note entered at 4:38 PM on 10/19/17, documented that the resident was discharged and the time of discharge was 4:00 PM. The note continued that the resident was discharged by car with NH staff and stated the reason for the discharge was for admission. The note documented that the Physician and/or RP notified in standard text, and added in narrative that the physician was notified but that the responsible party actually was not reached and therefore was not notified and consent to move the resident was not obtained. Although staff documented the physician was notified at the time of the discharge, review of the medical record revealed that there was no physician order allowing staff to discharge the resident at the time that staff drove the resident to the next nursing home. A physician order was not entered into the medical record until 6:42 PM on 1/19/16 (nearly three hours after staff drove the resident from the nursing home). On 1/18/17, when surveyors requested to interview the staff that drove Resident #1 from the nursing home, the Administrator was also unable to determine just what staff it might have been that drove the resident from the facility on 10/19/17. This was also not documented. In interview with staff at the next facility where resident #1 was driven on 10/19/16, the staff stated that she called the RP after Resident #1 had arrived. The staff member said that the resident ' s son was angry and said that he had not been told his parent was being transferred. With no order, no notice, no consent, and no documented rationale, unqualified staff working outside their allowed scope of practice drove Resident #1 to another facility nearly 70 miles further away from the family. (Staff cannot assess and decide to discharge a resident with no physician documented rationale and with no physician order.) Review of the medical record on 1/18/16 revealed that on the day after discharge, on 10/20/16 at 10:48 AM the physician entered a discharge summary note that stated the discharge rationale was behavior was bothering other residents who are being at the rehab center for recovery; (he/she) had to be transferred to another facility to be in a closed unit. In interviews with the discharge planning staff on 1/18/17 at 9:20 and with the former social service assistant by phone on 1/19/17 at 5:00 PM, both corroborated that Resident #1 wandered and went in and out of other resident rooms which was intrusive. In interview on 1/26/17 at 10:45 AM with the Medical Director who was the attending for Resident #1, she corroborated that the reason for the discharge was that Resident #1 needed to be on a locked unit. Review of the medical record on 1/18/16 revealed that at the time of discharge, facility staff also failed to conduct sufficient discharge preparation as required to ensure the resident was actually going to a bed on a secure unit. Although not documented until after the discharge, the explicit reason for the transfer was the need for the resident to be on a secure unit for safety. However, with no discharge planning evidenced in the record at all, staff took resident #1 by car to the next location where a bed on the secure unit was actually not available. 5. Review of facility policy on 1/18/17 revealed that by policy, in effect since 4/11/06 and last revised on 12/1/13, the facility has routinely issued inappropriate notices of intent to discharge residents in their care for non-payment when non-payment has actually not occurred. The facility policy specifically requires that the facility be paid in advance and if residents might not be able to pay in advance in the future when the prescribed 100 day Medicare coverage ends residents are immediately discharged . The regulations do not allow facilities to preemptively issue notice to evict a resident on the basis that they might not receive payment in advance when the Medicare coverage period ends. The facility Notice of Involuntary Discharge Policy documents that it is the policy of (NMS) that 30 days prior to the last covered day of service, where payment has not been made in advance (and third-party coverage is ending), a resident will receive notice of intent to involuntarily discharge the resident. Review of medical records revealed that with insufficient basis both Resident #5 and Resident #8 were issued notice of intent to involuntarily discharge based on nonpayment and both were then subsequently discharged . 6. Review of the medical record revealed that Resident# 2 was admitted to the facility in July 2016 for rehabilitation and possible long-term care. On 8/11/16 the Nurse Practitioner noted the resident had impaired judgment and on 8/30/16 the physician reported the resident was evaluated for capacity. The physician noted that Resident #2 lacked capacity to make decisions and had poor understanding of the choices he/she makes. Review of a complaint (MD 035) on 1/18/17 revealed an allegation that the facility staff transferred Resident #2 to the hospital for evaluation of an acute condition and then refused to accept the resident back to the nursing home because the resident owed the facility money. This concern was substantiated. Review of the medical record revealed that on 8/11/16 the resident was issued a 30 day notice of pending involuntary discharge. Although the practice is noncompliant, by policy the facility issues these notices preemptively when the facility believes there may be refusal by residents or their family members to pay for services in advance after the Medicare benefit period expires. The facility Notice of Involuntary Discharge Policy last revised 12/1/13 directs that it is the policy of (NMS) that 30 days prior to the last covered day of service, where payment has not been made in advance (and third-party coverage is ending), a resident will receive notice of intent to involuntarily discharge the resident. Review of the nursing home medical record revealed that Resident #2 was sent to the hospital on [DATE] and consistent with regulatory requirements, the facility documented in the medical record that the resident was expected to return to the facility. A hospital progress note dated 11/2/16 reported the resident was cleared for discharge backed to the nursing home on 10/29/16. However, on 10/29/16 at 13:12 the hospital case manager documented that he/she contacted the nursing home regarding the resident ' s return and was told the bed was no longer available. The case manager further noted that facility staff advised the resident had an outstanding balance and blamed the family for not cooperating with applying for Medicaid. However, review of the nursing home record revealed that the nursing home had not provided sufficient discharge planning assistance to the family. On 10/31/16 the hospital case manager was notified that the resident was by then ready for discharge. Upon contacting the facility ' s liaison the case manager was told the resident would not be able to return to the facility due to the outstanding balance. Review of hospital case management notes revealed that after the nursing home transferred the resident to the hospital and refused to accept the resident back, the hospital social service staff provided the discharge planning services which the nursing home had not. Hospital social service staff assisted the resident ' s responsible party to obtain power of attorney designation to be able to access the resident ' s financial accounts. With nursing home policy in place to demand advance payment, the hospital record documented in an 11/2/16 note that the RP had sent a check to the facility and the facility still refused to accept the resident back until they received the check and could verify that it was the amount (he/she) owes. Another hospital progress note dated 11/16/16 reported the resident was still stable for discharge and that the nursing home was still refusing to readmit the resident indicating that they had not received documents needed to apply for Medicaid. Working with families of nursing home residents on the Medicaid application process is however the responsibility of the nursing home. An 11/18/16 hospital social services note indicated that the hospital social services staff was able to secure level of care (approval) for Maryland Medicaid funding for Resident #2. Hospital social service staff then was able to secure a secondary payer to satisfy the nursing home demand that payment be secured before accepting the resident back. On 12/7/16, when the facility was notified that the hospital had arranged for insurance authorization, the Administrator still refused to accept the resident back and demanded to have a meeting with the son first. The hospital record documented CM explained patient needs to go if (the authorization) is obtained and they still insisted on meeting the son and CM. Hospital social service staff coordinated filing the application for Maryland Medicaid which the resident did qualify for. The resident was then sent to another nursing home after the hospital provided all of the discharge planning services necessary to meet the needs of Resident #2. During an interview with the Staff #1 on 1/17/17 at 10:05 he/she was asked why the resident was not accepted for readmission. Staff #1 stated the facility attempted to assist the resident ' s family member in completing an application for Medicaid so that the resident could continue his/her stay at the facility, but the family member did not cooperate. No documented evidence supported this was accurate and the family member in fact cooperated fully when offered discharge planning assistance in the hospital. In interview with the surveyor on 1/17/17 at 11:25 AM the Administrator stated there was a meeting at the hospital to discuss the application for Long-Term Care Medical Assistance. The meeting was attended by the Administrator, the facility ' s attorney, a hospital social worker and case manager. The Administrator stated they discussed how much money the resident owed the nursing home and that during the 6 weeks the resident was in the hospital they tried to get the documents from the family member and tried to work with the hospital. This was inaccurate. The nursing home sent the resident to the hospital, refused to accept the resident back, and did not assist in provision of discharge planning services that the hospital provided including obtaining the needed paperwork for the Resident to qualify for Maryland Medicaid. During an interview with surveyor #2 on 1/19/17 at 10:45 the hospital social worker reported he/she assisted the family member with getting Power of Attorney in order to access the resident ' s account. The hospital social work staff also indicated that the RP sent 2 checks to the facility towards the resident ' s outstanding balance but the facility still declined to readmit the resident. The facility preemptively issued notice of involuntary discharge on 8/11/16 in violation of regulatory standards, and then involuntarily discharged the resident to a hospital emergency room while documenting in the medical record it was a discharge for which they anticipated resident return. Documenting that this was an appropriate discharge with return expected was inaccurate as the facility later acknowledged to the hospital that consistent with the noncompliant facility policies for involuntary discharges, there was no intention to accept Resident #2 back. Resident #2 remained in a hospital bed for 30 days while the hospital provided the family the needed discharge planning services that the nursing home had failed to provide, while the nursing home repeatedly refused to accept the resident back. 7. The facility failed to communicate a change in Resident #17 condition to a physician obtain an order for [REDACTED]. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED] is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. A hospital discharge summary dated 2/6/17 noted the medication, [MEDICATION NAME], used to treat the resident's pain associated with [DIAGNOSES REDACTED] was on hold as the resident was not in pain at that time. [MEDICATION NAME] is an anticonvulsant that is also used for nerve pain. A Concurrent Review Form dated 2/19/17 at 2:59 PM reported the resident complained of gum pain. The writer noted an attempt to contact the physician at 2:55 PM with no response by the physician. The medical record did not contain documentation of any further attempts to contact the physician. A Concurrent Review Form dated 2/20/17 at 3:29 PM noted that at 1:30 PM the Resident complained of sharp pain in her/his gums. The writer further noted the physician was notified at 1:40 PM and gave an order to administer [MEDICATION NAME] 300 milligrams three times a day. A physician's note dated 2/21/17 reported the resident was experiencing facial pain, had been off [MEDICATION NAME] and pain free until 2/20/17 when she/he developed severe pain in the left side of the face, mainly mouth, gums and lips. The physician further noted it was neuropathic pain. Review of the Medication Administration Record [REDACTED]. During an interview with the surveyor on 2/27/17 at 10:12 AM the resident recalled the onset of the facial pain and indicated talking and chewing increases the pain. In interview with the surveyor on 2/27/17 at 12:47 PM the Director of Nursing (DON) confirmed the facility's expectation that resident's pain be promptly managed and if a physician failed to respond to a call the nurse is to contact another physician, the Medical Director and/or the DON. In a follow-up interview with the DON on 2/27/17 at 1:51 PM he/she stated that an interview with Nurse #1 confirmed he/she took no further action in an attempt to reach a physician or obtain an order for [REDACTED].>Medical record review, staff and resident interview revealed facility staff failed to communicate Resident #17 change in condition to a physician and ensure that the resident's pain was promptly managed.

Based on interviews with staff and review of medical record and other pertinent documentation, the facility failed to ensure sufficient physician oversight of medical care by implementing noncompliant systems for admissions, discharges and provision of care that resulted in all of the following. (1) Without clinical review by sufficiently qualified staff, with no oversight or order from the physician, and with no notification or consent from the responsible family, non-clinical facility staff admitted a cognitively impaired resident (Resident #1) for whom the facility did not have capability to meet his/her known clinical needs. (2) While under the care of the Medical Director, the facility failed to ensure staff documented and reported an elopement attempt when resident #1 was able to get out of the building, failed to conduct any investigation of the elopement attempt, and failed to immediately ensure the building was secure after the elopement attempt. (3) With no discharge planning, no discharge order, no notice or consent from the responsible party, and woefully insufficient preparation, facility staff operating outside their scope of practice discharged Resident #1 by driving him/her to another facility in a distant county that also did not have the capability to meet his/her needs. (4) The physician enabled staff to practice outside their allowable scope of practice by providing staff the order for the admission of Resident #1 after the admission was already completed by nonclinical facility staff, by providing the order for discharge of Resident #1 after the inappropriate discharge on 10/19/16 had already been completed by staff, and by documenting the rationale for the discharge of Resident #1 after staff had already completed the inappropriate discharge. This concern was evident for 1/16 residents reviewed during survey. The failure by the facility to meet minimum standards to ensure effective physician oversight of medical care provided in the facility contributed to resident rights violations where Resident #1 was admitted and discharged without ever obtaining consent leaving family members not even knowing where their love one was and resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:20 PM on 1/18/17; and the facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 11:49 PM on 1/18/17 while surveyors remained onsite. The plan included: The facility conducted an immediate audit of all residents at risk for elopement to ensure that appropriate interventions were in place. WanderGuard systems and locking door mechanisms are to be checked weekly. Admissions staff were educated on consent requirements and on admission criteria. A process was instituted where the Administrator will ensure consents are obtained before admissions. Discharge planning staff were educated on consent, need to obtain bed availability in writing when resident is discharging, and need to start discharge planning process on admission. Physicians will be reeducated on importance of providing discharge orders timely. All staff to be reeducated on policy that elopement and elopement attempts must be documented in the medical record. DON will review elopement attempts and/or events in the facility morning meetings. Discharge planning notes will be reviewed in morning meeting for any resident to be discharged to ensure discharge is planned and safe. Administrator will now also review each discharge prior to discharge to ensure acceptance of resident at next provider of care as applicable. The DON will audit three discharges per week to determine if policies are followed and audits will be reported into the facility QA Committee for oversight. The survey findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident ' s needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions/items. Each triggered care area must then be assessed in order to determine if care planning is needed; and if so to drive an effective plan that will ensure the assessed needs of each resident are met when care is delivered. 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. All staff must review and understand the plan so that care is delivered in a consistent manner across all days, shifts and disciplines. Resident dumping is the act of discharging a resident for reasons not allowed in regulation and often to inappropriate and unsafe locations. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. The Wander Guard management system incorporates a sensor that triggers an alarm when the sensor is detected by a monitoring device. Staff can ensure that vulnerable residents at risk for harm if they leave a facility building wear the sensor. The monitoring devices which detect the sensors are typically placed at potential exit locations so that staff will be alerted if residents wearing the sensor attempt to exit the building. 1. Without consent or clinical assessment, the facility admitted a cognitively impaired resident (Resident #1) for whom they did not have capability to meet the resident ' s known needs. Resident #1 did not have decision making capacity. Documentation from the hospital admission immediately prior to this nursing home admission indicated that the hospital assisted in obtaining guardianship for the resident ' s son and hospital record documentation revealed that the resident ' s son was the resident ' s Responsible Party (RP). Soon after admission to the nursing home, two physicians corroborated in a formal certification that resident #1 did not have decision-making capacity and both physicians signed the certification on 10/11/16. Hospital documentation sent to the facility for review in making the decision for the possible admission, revealed multiple hospital care planning notes (including notes entered on 10/7/16, 10/8/16, 10/9/16, and 10/10/16) documenting that Resident #1 had intermittent agitation and hallucinations, and that he/she needs to go to facility with (a) dementia unit . Observation of the nursing home on 1/18/17 and interview with the Director of Nursing at 12:45 on 1/18/17 revealed that this facility does not have a secure (locked) unit. In interview with the Administrator on 1/18/17, he reported that the Admissions Coordinator has a degree in Business Administration and is not clinical. In interview on 1/18/17 at 10:00 AM, the Admissions Coordinator stated that she with assistance from the Administrator (a physical therapist with additional training in health care administration) decides who is and who is not admitted . She stated that only when she has a clinical concern that she can ' t figure out does she consult with the Director of Nursing (DON). In interview with the Director of Nursing at 12:45 PM on 1/18/17, she also corroborated that the Admissions Coordinator and Administrator determine who can and cannot be admitted and that she (the DON) only gets involved if they bring a concern to her. Compounding the concern with admission decisions having been delegated to a non-clinical coordinator with no clinical or medical oversight, in interview on 1/26/17 at 10:14 AM, the Admissions Manager stated that she does not keep any notes regarding communication with hospitals seeking placement for patients discharging from the hospital. She reported that she keeps a spreadsheet documenting only the resident ' s name, where they were transferred to/from, date of transfer, reason for transfer, and the name of the facility staff liaison. In interview on 1/18/17, when asked if the facility evaluated Resident #1 ' s need for a secure unit, the Admissions Coordinator inaccurately reported that nothing in the hospital record stated they needed a locked unit. Thus, although the hospital documented that resident #1 required placement on a secure unit, no clinical staff were made aware, nor questioned, nor evaluated if the placement to this facility which has no secure unit was safe and appropriate for this resident. The three day qualifying hospital stay (qualifies resident for Medicare benefit) had been from 10/7/16 through 10/10/16. After the qualifying stay, Resident #1 was admitted to an open unit in the facility on 10/10/16. The physician order to admit to the nursing home was entered into the nursing home medical record on 10/10/16 at 9:02 PM. Review of the nursing home admission agreement revealed that it was never signed to evidence consent by the resident ' s son for the resident ' s care and treatment in the facility. Although with no secure unit the facility could not meet the known needs of Resident #1, the risks and benefits of placing the Resident in this facility were never discussed with the decision-maker for Resident #1, and the responsible party never consented to admission. In interview on 1/18/17, the Administrator reported (and provided documentation showing) that staff was unable to reach the responsible party (RP) and stated that was why the agreement was never signed. The single page document indicated that a Social Services Assistant had called the RP on 10/11/16 and left a voice message. The document then indicated that no attempts to call were made on 10/12/16 because the resident was out of the facility (at the hospital for evaluation after a fall). Next, the document revealed that on 10/14/16 the staff called and spoke with the RP and documented RP may stop by this weekend but if not the RP will need the admission packet mailed out. No verbal request for consent was ever documented including during this call, and no further attempts to get the agreement signed were found documented in the medical record. Although the Administrator reported that the admission agreement was never signed because they could not reach the RP, review of the medical record on 1/18/17 revealed that facility staff was able to reach the resident ' s son at 8:20 PM on 10/11/16 when staff provided notice to the guardian that the resident had suffered a fall. Review of the medical record also revealed that facility staff documented they were able to reach the resident ' s son a second time at 1:30 PM on 10/12/16 when results of a scan had been obtained and results were reported to the RP. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a third time at 4:16 PM on 10/12/16 when staff provided notice that the resident had been sent to the hospital for evaluation of the symptoms/concerns related to the fall the prior day. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a fourth time at 3:30 PM on 10/16/16 when staff provided notice that the resident had new orders prescribed. Nonetheless, staff reported that the consent for the admission was never obtained because staff could never reach the resident ' s son. 2. The facility failed to ensure staff documented and reported an elopement attempt when resident #1 was able to get out of the building, failed to conduct any investigation of the elopement attempt, and failed to immediately ensure the building was secure after the elopement attempt. On 10/11/16 at 3:24 PM Resident #1 was assessed at risk for elopement and use of a WanderGuard system was implemented. Per staff interviews with the Social Services Manager, Discharge Planner, and QA Director (all on 1/18/17) the resident at some point got out of the building despite the use of the WanderGuard system. The event was never documented by any staff and no-one interviewed could recall exactly when the event occurred. In interview on 1/18/17 at 9:20 AM, the Discharge Planner and Social Services Manager reported they were working when Resident #1 left the building and went across the parking lot and passed the neighboring [MEDICAL TREATMENT] building. They reported that many staff members were involved in bringing him/her back inside and calming him/her down, including the Administrator, physical therapy staff and multiple nurses. The discharge planner stated that after they got the resident back into the building, she got him/her a soft drink which he/she likes and that helped calm him/her down. Despite the occurrence of an elopement attempt where the resident got completely out of the building requiring many staff to get him/her back, review of the medical record on 1/18/17 revealed that no concurrent review note was opened to ensure review of facility processes and follow up for the resident ' s needs, no nursing notes documented the event, and the resident care plan was not updated following the event where he/she was able to leave the building despite use of the WanderGuard system. In addition to failing to document the event in a concurrent review to ensure opening a prompt review and investigation, in interview on 1/18/17, the facility QA nurse acknowledged that there had been no investigation of the event. 3. The facility failed to provide any discharge planning services for Resident #1. Review of the medical record revealed that no discharge planning services were provided as required, as no discharge planning notes were entered through the resident ' s entire admission. The only discharge note in the medical record was entered after discharge on 10/20/16 at 10:21 AM. This note documented, discharged : Resident was discharged on [DATE] to NMS Hagerstown. After searching with electronic record access during 12:45 interview on 1/18/17, the Director of Nursing corroborated that there were no discharge planning notes in the medical record for Resident #1. In interview with discharge planning staff #1 at 9:20 AM on 1/18/17, she reported that (former) staff #2 was assigned to Resident #2 for discharge planning. In interview by telephone at 5:00 PM on 1/18/17, former staff #2 stated that he wasn ' t assigned to provide discharge planning for resident #1 and he didn ' t know who was. 4. With no documented rationale at the time of discharge, no discharge planning, no discharge order, and no consent, facility staff discharged Resident #1and drove him/her to another facility in a distant county that also did not have the capability to meet his/her needs. A 10/19/17 note in the nursing section of the medical record revealed that the transfer was not urgent as Resident #1 was stable at the time of the discharge. This note documented that Resident #1 was calm and cooperative with care, no behavioral issues noted. Safety and falls precautions (were) maintained during transport. Further, the resident was noted as alert and verbally responsive, appears in no distress. Breathing even and unlabored, lung sounds clear bilaterally upon auscultation. Abdomen soft and non-tender, bowel sounds present in all quadrants. Skin warm and dry to touch. On 10/19/16 with no clinical review, with no order, with no consent, with insufficient discharge preparation to ensure the next facility could meet the resident ' s needs (where he/she needed the secure unit), and with evidence of no discharge planning having ever been provided, on 10/19/17 staff transferred Resident #1 to another sister-facility (same corporate ownership). The rationale for the decision to transfer the resident was not documented by any staff, anywhere in the medical record prior to the discharge. Review of the record revealed that on the following day, the physician entered a discharge note at 10:48 AM on 10/20/16 (after the discharge) indicating that the resident had to be discharged to another facility as (he/she) requires closed unit. A nursing discharge note entered at 4:38 PM on 10/19/17, documented that the resident was discharged and the time of discharge was 4:00 PM. The note continued that the resident was discharged by car with NH staff and stated the reason for the discharge was for admission. The note documented that the Physician and/or RP notified in standard text, and added in narrative that the physician was notified but that the responsible party actually was not reached and therefore was not notified and consent to move the resident was not obtained. Although staff documented the physician was notified at the time of the discharge, review of the medical record revealed that there was no physician order allowing staff to discharge the resident at the time that staff drove the resident to the next nursing home. A physician order was not entered into the medical record until 6:42 PM on 1/19/16 (nearly three hours after staff drove the resident from the nursing home). On 1/18/17, when surveyors requested to interview the staff that drove Resident #1 from the nursing home, the Administrator was also unable to determine just what staff it might have been that drove the resident from the facility on 10/19/17. This was also not documented. In interview with staff at the next facility where resident #1 was driven on 10/19/16, the staff stated that she called the RP after Resident #1 had arrived. The staff member said that the resident ' s son was angry and said that he had not been told his parent was being transferred. With no order, no notice, no consent, and no documented rationale, unqualified staff working outside their allowed scope of practice drove Resident #1 to another facility nearly 70 miles further away from the family. (Staff cannot assess and decide to discharge a resident with no physician documented rationale and with no physician order.) Review of the medical record on 1/18/16 revealed that on the day after discharge, on 10/20/16 at 10:48 AM the physician entered a discharge summary note that stated the discharge rationale was behavior was bothering other residents who are being at the rehab center for recovery; (he/she) had to be transferred to another facility to be in a closed unit. In interviews with the discharge planning staff on 1/18/17 at 9:20 and with the former social service assistant by phone on 1/19/17 at 5:00 PM, both corroborated that Resident #1 wandered and went in and out of other resident rooms which was intrusive. In interview on 1/26/17 at 10:45 AM with the Medical Director who was the attending for Resident #1, she corroborated that the reason for the discharge was that Resident #1 needed to be on a locked unit. Review of the medical record on 1/18/16 revealed that at the time of discharge, facility staff also failed to conduct sufficient discharge preparation as required to ensure the resident was actually going to a bed on a secure unit. Although not documented until after the discharge, the explicit reason for the transfer was the need for the resident to be on a secure unit for safety. However, with no discharge planning evidenced in the record at all, staff took resident #1 by car to the next location where a bed on the secure unit was actually not available. 5. The physician enabled staff to practice outside their allowable scope of practice contributing to the resident rights violations where Resident #1 was admitted and later discharged without notice to or consent from the RP. The physician enabled these unsafe staff practices by (1) providing staff the order for admission of Resident #1 after staff had already completed the unsafe admission on 10/10.16, by providing staff an order for [REDACTED]. In interview on 1/26/17 at 10:45 AM, the Medical Director, who was the attending for Resident #1, indicated that she does not necessarily review information regarding new admissions and that staff do not always notify her of pending admissions. She reported that her understanding was that the Admissions Manager and NMS Liaison review the resident ' s record and decide whether or not to admit. Review of the medical record revealed that resident #1 was admitted to the facility on [DATE] at 4:45 PM. In interview on 1/26/17 at 10:45 AM with the Medical Director who was the attending for Resident #1, she indicated that she was not notified of Resident #1 ' s pending admission and was not made aware of the documented resident need for a secure unit. More than four hours after facility staff had completed the admission with no consent and with no clinical assessment or evaluation to determine if the resident ' s needs could actually be met in this facility, the Medical Director gave staff the order for the 4:45 PM admission on 10/10/16 at 9:02 PM. After staff admitted the resident with no clinical review, no order, no consent, with ineffective screening measures to ensure the facility could meet the resident ' s needs (where he/she needed the secure unit), on 10/19/17 staff then transferred Resident #1 to another sister-facility (same corporate ownership), without notice to the RP, without consent from the RP, with no documented rationale for the discharge and without any discharge preparation or planning. A discharge note entered at 4:38 PM on 10/19/17, documented that the resident was discharged and the time of discharge was 4:00 PM. The note continued that the resident was discharged by car with NH staff and stated the reason for the discharge was for admission. The note documented that the Physician and/or RP notified in standard text, and added in narrative that the physician was notified but that the responsible party actually was not reached and therefore was not notified and consent to move the resident was not obtained. As was true with the admission, review of the medical record revealed that there was no physician order allowing staff to discharge the resident at the time that staff drove the resident to the next nursing home. The physician order was not entered into the medical record until hours after staff had already discharged Resident #1 at 6:42 PM on 1/19/16. The day after discharge, on 10/20/16 at 10:48 AM the physician entered a discharge summary note which documented the discharge rational had been that resident behavior was bothering other residents who are being at the rehab center for recovery; (he/she} had to be transferred to another facility to be in a closed unit. In interviews with the discharge planning staff on 1/18/17 at 9:20 and with the former social service assistant by phone on 1/19/17 at 5:00 PM, both corroborated that Resident #1 wandered and went in and out of other resident rooms which was intrusive. Though not documented in the discharge summary note, in interview with the Medical Director on 1/26/17 at 10:45 AM, she added that there were also safety concerns after Resident #1 had made the elopement attempt which was considered in the rationale and determination that he/she needed to be on a secure unit. At the time of discharge, facility staff also failed to conduct sufficient discharge preparation as required to ensure the resident was actually going to a bed on a secure unit. Although the explicit reason for the transfer documented by the physician (after the discharge) was the need for the resident to be on a secure unit for safety, at the time of the discharge no bed was available on the secure unit at the receiving nursing home but staff discharged him/her anyway. Therefore, without appropriate physician oversight of medical care provided, after putting the confused resident through the stress of the inappropriate discharge, he/she was placed on an open unsecure unit and his/her needs were therefore still not appropriately met.

Based on staff interviews and review of medical record and other pertinent documentation the facility failed to ensure effective use of resources by facility administration to ensure maintenance of the highest practicable physical, mental, and psychosocial well-being of each resident, when the facility implemented noncompliant practices for admissions and discharges, failed to ensure appropriate oversight by medical staff, and allowed front line staff to operate far outside their skills, qualifications, or allowed scopes of practice. These interrelated failures resulted in resident rights violations when Resident #1 was both admitted and later discharged by facility staff acting outside their scope of practice without appropriate physician orders, without notification to the responsible party and family, and without obtaining required consent, leaving family unaware even of where their love one was located. This concern was evident for 1/16 residents reviewed during survey. The noncompliant admission and discharge practices affecting Resident #1 resulted in determination by the Maryland Office of Health Care Quality (OHCQ) that a condition of Immediate Jeopardy existed. The facility was notified of the Immediate Jeopardy at 4:20 PM on 1/18/17; and the facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 11:49 PM on 1/18/17 while surveyors remained onsite. The plan included: - The facility conducted an immediate audit of all residents at risk for elopement to ensure that appropriate interventions were in place. - WanderGuard systems and locking door mechanisms are to be checked weekly. - Admissions staff were educated on consent requirements and on admission criteria. - A process was instituted where the Administrator will ensure consents are obtained before admissions. - Discharge planning staff were educated on consent, need to obtain bed availability in writing when resident is discharging, and need to start discharge planning process on admission. - Physicians will be reeducated on importance of providing discharge orders timely. - All staff to be reeducated on policy that elopement and elopement attempts must be documented in the medical record. DON will review elopement attempts and/or events in the facility morning meetings. - Discharge planning notes will be reviewed in morning meeting for any resident to be discharged to ensure discharge is planned and safe. - Administrator will now also review each discharge prior to discharge to ensure acceptance of resident at next provider of care as applicable. - The DON will audit three discharges per week to determine if policies are followed and audits will be reported into the facility QA Committee for oversight. The survey findings include: The Resident Assessment Instrument (RAI) is a mandated process that ensures residents in nursing homes receive comprehensive and periodic assessments that are both standardized and reproducible to ensure each resident ' s needs are clearly understood and that care can be appropriately and effectively planned and delivered (based on the assessment). The Minimum Data Set (MDS) is a core set of screening questions that provide the foundation for the RAI process. Providers must complete the MDS screening assessments at specified times during resident admissions. Some MDS assessments are comprehensive and others are abbreviated updates to the comprehensive assessments. After completion of any comprehensive MDS assessment, the MDS triggers care areas based on the responses to the MDS questions/items. Each triggered care area must then be assessed in order to determine if care planning is needed; and if so to drive an effective plan that will ensure the assessed needs of each resident are met when care is delivered. 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. All staff must review and understand the plan so that care is delivered in a consistent manner across all days, shifts and disciplines. Resident dumping is the act of discharging a resident for reasons not allowed in regulation and often to inappropriate and unsafe locations. Elopement is an event when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. The Wander Guard management system incorporates a sensor that triggers an alarm when the sensor is detected by a monitoring device. Staff can ensure that vulnerable residents at risk for harm if they leave a facility building wear the sensor. The monitoring devices which detect the sensors are typically placed at potential exit locations so that staff will be alerted if residents wearing the sensor attempt to exit the building. 1. Without consent or assessment, the facility admitted a cognitively impaired resident (Resident #1) for whom they did not have capability to meet the resident ' s known needs. Resident #1 did not have decision making capacity. Documentation from the hospital admission immediately prior to this nursing home admission indicated that the hospital assisted in obtaining guardianship for the resident ' s son and hospital record documentation revealed that the resident ' s son was the resident ' s decision-maker. Soon after admission to the nursing home, two physicians corroborated in a formal certification that resident #1 did not have decision-making capacity and both physicians signed the certification on 10/11/16. Hospital documentation sent to the facility for review in making the decision for the possible admission, revealed multiple hospital care planning notes (including notes entered on 10/7/16, 10/8/16, 10/9/16, and 10/10/16) documenting that Resident #1 had intermittent agitation and hallucinations, and that he/she needs to go to facility with (a) dementia unit . Observation of the nursing home on 1/18/17 and interview with the Director of Nursing at 12:45 on 1/18/17 revealed that the facility does not have a secure (locked) unit. In interview with the Administrator on 1/18/17, he reported that the Admissions Coordinator has a degree in Business Administration and is not clinical. In interview on 1/18/17 at 10:00 AM, the admissions coordinator stated that she with assistance from the Administrator (a physical therapist with additional training in health care administration) decide who is and who is not admitted . She stated that only when she has a clinical concern that she can ' t figure out does she consults with the Director of Nursing (DON). In interview with the Director of Nursing at 12:45 PM on 1/18/17, she also corroborated that the Admissions Coordinator and Administrator determine who can and cannot be admitted and that she only gets involved if they bring a concern to her. Compounding the concern with admission decisions having been delegated to a non-clinical coordinator, in interview on 1/26/17 at 10:14 AM, the Admissions Manager stated that she does not keep any notes regarding communication with hospitals seeking placement for patients discharging from the hospital. She reported that she keeps a spreadsheet documenting only the resident ' s name, where they were transferred to/from, date of transfer, reason for transfer, and the name of the facility staff liaison. In interview on 1/18/17, when asked if the facility evaluated Resident #1 ' s need for a secure unit, the Admissions Coordinator inaccurately reported that nothing in the hospital record stated they needed a locked unit. Thus, although the hospital documented that resident #1 required placement on a secure unit, no clinical staff were made aware, nor questioned, nor evaluated if the placement to this facility which has no secure unit was safe and appropriate for this resident. The three day qualifying hospital stay (qualifies resident for Medicare benefit) had been from 10/7/16 through 10/10/16. After the qualifying stay, Resident #1 was admitted to an open unit in the facility on 10/10/16. The physician order to admit to the nursing home was entered into the nursing home medical record on 10/10/16 at 9:02 PM. Review of the nursing home admission agreement revealed that it was never signed to evidence consent by the resident ' s son for the resident ' s care and treatment. Although the facility could not meet the known needs of Resident #1, the risks and benefits of placing the Resident in this facility were never discussed with the decision-maker for Resident #1, and the responsible party never consented to admission. In interview on 1/18/17, the Administrator reported (and provided documentation showing) that staff was unable to reach the responsible party (RP) and that was why the agreement was never signed. The single page document indicated that a Social Services Assistant called the RP on 10/11/16 and left a voice message. The document then indicated that no attempts to call were made on 10/12/16 because the resident was out of the facility (at the hospital for evaluation after a fall). Next, the document revealed that on 10/14/16 the staff called and spoke with the RP and documented RP may stop by this weekend but if not the RP will need the admission packet mailed out. No verbal request for consent was ever documented including during this call, and no further attempts to get the agreement signed were found documented in the medical record. Although the Administrator reported that the admission agreement was never signed because they could not reach the responsible party, review of the medical record on 1/18/17 revealed that facility staff was able to reach the resident ' s son at 8:20 PM on 10/11/16 when staff provided notice to the guardian that the resident had suffered a fall. Review of the medical record also revealed that facility staff documented they were able to reach the resident ' s son a second time at 1:30 PM on 10/12/16 when results of a scan had been obtained and results were reported to the RP. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a third time at 4:16 PM on 10/12/16 when staff provided notice that the resident had been sent to the hospital for evaluation of the symptoms/concerns related to the fall the prior day. Review of the medical record revealed that facility staff documented they were able to reach the resident ' s son a fourth time at 3:30 PM on 10/16/16 when staff provided notice that the resident had new orders prescribed. Nonetheless, staff reported that the consent for the admission was never obtained because staff could never reach the resident ' s son. The facility Administration failed to ensure effective systems with clinical accountability were developed and implemented for the adequate assessment and evaluation potential resident admissions, failed to ensure residents whose needs cannot be met will not be admitted , and failed to ensure effective processes will ensure that admissions and discharges will not be completed without appropriate review of consent and without notice to responsible parties. 2. The facility failed to ensure staff documented and reported an elopement attempt when resident #1 was able to get out of the building, failed to conduct any investigation of the elopement attempt, and failed to immediately ensure the building was secure after the elopement attempt. On 10/11/16 at 3:24 PM Resident #1 was assessed at risk for elopement and use of a WanderGuard system was implemented. Per staff interviews with the Social Services Manager, Discharge Planner, and QA Director (all on 1/18/17) the resident at some point got out of the building despite the use of the WanderGuard system. The event was never documented by any staff and no-one interviewed could recall exactly when the event occurred. In interview on 1/18/17 at 9:20 AM, the Discharge Planner and Social Services Manager reported they were working when Resident #1 left the building and went across the parking lot and passed the neighboring [MEDICAL TREATMENT] building. They reported that many staff members were involved in bringing him/her back inside and calming him/her down, including the Administrator, physical therapy staff and multiple nurses. The discharge planner stated that after they got him/her back into the building, she got him/her a soft drink which he/she likes and that helped calm him/her down. Despite the occurrence of an elopement attempt where the resident got completely out of the building requiring many staff to get him/her back, review of the medical record on 1/18/17 revealed that no concurrent review note was opened to ensure review of facility processes and follow up for the resident ' s needs, no nursing notes documented the event, and the resident care plan was not updated following the event where he/she was able to leave the building despite use of the WanderGuard system. In addition to failing to document the event in a concurrent review to ensure opening a prompt review and investigation, in interview on 1/18/17, the facility QA nurse acknowledged that there had been no investigation of the event. Facility administration failed to ensure internal systems for reporting adverse events and unsafe situations into facility QAPI systems were functional and effective so that management could be made aware and could be able to address potential areas of concern in the facility care delivery systems. 3. The facility failed to provide any discharge planning services for Resident #1. Review of the medical record revealed that no discharge planning services were provided as required, as no discharge planning notes were entered through the resident ' s entire admission. The only discharge note in the medical record was entered after discharge on 10/20/16 at 10:21 AM. This note documented, discharged : Resident was discharged on [DATE] to NMS Hagerstown. After searching with electronic record access during 12:45 interview on 1/18/17, the Director of Nursing corroborated that there were no discharge planning notes in the medical record for Resident #1. In interview with discharge planning staff #1 at 9:20 AM on 1/18/17, she reported that staff #2 was assigned to Resident #2 for discharge planning but that he no longer worked in the facility. In interview by telephone at 5:00 PM on 1/18/17, former staff #2 stated that he wasn ' t assigned to provide discharge planning for resident #1 and he didn ' t know who was. 4. With no documented rationale at the time of discharge, no discharge planning, no discharge order, and no consent, facility staff discharged Resident #1and drove him/her to another facility in a distant county that also did not have the capability to meet his/her needs. A 10/19/17 note in the nursing section of the medical record revealed that the transfer was not urgent as Resident #1 was stable at the time of the discharge. This note documented that Resident #1 was calm and cooperative with care, no behavioral issues noted. Safety and falls precautions (were) maintained during transport. Further, the resident was noted as alert and verbally responsive, appears in no distress. Breathing even and unlabored, lung sounds clear bilaterally upon auscultation. Abdomen soft and non-tender, bowel sounds present in all quadrants. Skin warm and dry to touch. On 10/19/16 with no clinical review, with no order, with no consent, with ineffective screening measures to ensure the next facility could meet the resident ' s needs (where he/she needed the secure unit), and with evidence of no discharge planning having ever been provided, on 10/19/17 staff transferred Resident #1 to another sister-facility (same corporate ownership). The rationale for the decision to transfer the resident was not documented by any staff, anywhere in the medical record prior to the discharge. Review of the record revealed that on the following day, the physician entered a discharge note at 10:48 AM on 10/20/16 (after the discharge) indicating that the resident had to be discharged to another facility as (he/she) requires closed unit. A nursing discharge note entered at 4:38 PM on 10/19/17, documented that the resident was discharged and the time of discharge was 4:00 PM. The note continued that the resident was discharged by car with NH staff and stated the reason for the discharge was for admission. The note documented that the Physician and/or RP notified in standard text, and added in narrative that the physician was notified but that the responsible party actually was not reached and therefore was not notified and consent to move the resident was not obtained. Although staff documented the physician was notified at the time of the discharge, review of the medical record revealed that there was no physician order allowing staff to discharge the resident at the time that staff drove the resident to the next nursing home. A physician order was not entered into the medical record until 6:42 PM on 1/19/16 (nearly three hours after staff drove the resident from the nursing home). On 1/18/17, when surveyors requested to interview the staff that drove Resident #1 from the nursing home, the Administrator was also unable to determine just what staff it might have been that drove the resident from the facility on 10/19/17. This was also not documented. In interview with staff at the next facility where resident #1 was driven on 10/19/16, the staff stated that she called the RP after Resident #1 had arrived. The staff member said that the resident ' s son was angry and said that he had not been told his parent was being transferred. With no order, no notice, no consent, and no documented rationale, unqualified staff working outside their allowed scope of practice drove Resident #1 to another facility nearly 70 miles further away from the family. The day after discharge, on 10/20/16 at 10:48 AM the physician entered a discharge summary note that stated the rationale was behavior was bothering other residents who are being at the rehab center for recovery; (he/she) had to be transferred to another facility to be in a closed unit. In interviews with the discharge planning staff on 1/18/17 at 9:20 and with the former social service assistant by phone on 1/19/17 at 5:00 PM, both corroborated that Resident #1 wandered and went in and out of other resident rooms which was intrusive. In interview on 1/26/17 at 10:45 AM with the Medical Director who was the attending for Resident #1, she corroborated that the reason for the discharge was that Resident #1 needed to be on a locked unit. At the time of discharge, facility staff also failed to conduct sufficient discharge preparation as required to ensure the resident was actually going to a bed on a secure unit. Although documented after the discharge, the explicit reason for the transfer was the need for the resident to be on a secure unit for safety. However, with no discharge planning evidenced in the record at all, the staff took resident #1 by car to the next location where a bed on the secure unit was actually not available. Facility Administration failed to ensure effective systems to identify and address problem prone areas when systemic noncompliance in admission and discharge practices were readily identifiable by the survey team but were not identified and addressed through facility QAPI systems. 5. The physician enabled staff to practice outside their allowable scope of practice contributing to the resident rights violations where Resident #1 was admitted and later discharged without notice to or consent from the RP. The physician enabled these unsafe staff practices (1) by providing staff an order for [REDACTED]. In interview on 1/26/17 at 10:45 AM with the Medical Director who was the attending for Resident #1, she indicated that she does not necessarily review information regarding new admissions and that staff do not always notify her of pending admissions. She reported that her understanding for admissions was that the Admissions manager and NMS Liaison review the resident ' s record and decide whether or not to admit. Review of the medical record revealed that resident #1 was admitted to the facility on [DATE] at 4:45 PM. In interview on 1/26/17 at 10:45 AM with the Medical Director who was the attending for Resident #1, she indicated that she was not notified of Resident #1 ' s pending admission and was not made aware of the documented resident need for a secure unit. More than four hours after facility staff had completed the admission with no consent and with no documented clinical assessment or evaluation to determine if the resident ' s needs could actually be met in this facility, the Medical Director gave staff an order for [REDACTED]. After staff admitted the resident on 10/10/16 with no clinical review, no order, no consent, and with ineffective screening measures to ensure the facility could meet the resident ' s needs (where he/she needed the secure unit), on 10/19/17 staff then transferred Resident #1 to another sister-facility (same corporate ownership) without notice to the RP again, without consent from the RP again, with no documented discharge rationale, and with no discharge preparation or planning. A discharge note entered at 4:38 PM on 10/19/17, documented that the resident was discharged and the time of discharge was 4:00 PM. The note continued that the resident was discharged by car with NH staff and stated the reason for the discharge was for admission. The note documented that the Physician and/or RP notified in standard text, and added in narrative that the physician was notified but that the responsible party actually could not be reached and therefore was not notified and consent to move the resident was not obtained. As was true with the admission, review of the medical record revealed that there was no physician order allowing staff to discharge the resident at the time that staff drove the resident to the next nursing home. The physician order was not entered into the medical record until 6:42 PM on 1/19/16; hours after staff had already discharged Resident #1. The day after discharge, on 10/20/16 at 10:48 AM the physician entered a discharge summary note which documented the discharge rational had been that resident behavior was bothering other residents who are being at the rehab center for recovery; (he/she) had to be transferred to another facility to be in a closed unit. In interviews with the discharge planning staff on 1/18/17 at 9:20 and with the former social service assistant by phone on 1/19/17 at 5:00 PM, both corroborated that Resident #1 wandered and went in and out of other resident rooms which was intrusive. Facility staff had also failed to conduct sufficient discharge preparation prior to discharge as required. Although the explicit discharge reason was the need for the resident to be on a secure unit, at the time of the discharge no bed was available on the secure unit at the receiving nursing home but staff discharged him/her anyway. Therefore, after discharge the resident need for a secure unit still was not met. Facility Administration failed to ensure effective systems to identify and address problem prone areas when systemic noncompliance in admission and discharge practices, including clinical and medical oversight failures, were readily identifiable by the survey team but were not identified and addressed through facility QAPI systems. 6. The facility implemented and enforced noncompliant policy to involuntarily discharge residents for alleged but nonexistent nonpayment when resident bills were not paid in advance. By policy, in effect since 4/11/06 and last revised on 12/1/13, the facility has routinely issued inappropriate notices of intent to discharge residents in their care for non-payment when non-payment has actually not occurred. Policy specifically requires that the facility be paid in advance and if residents might not pay in advance in the future when the prescribed 100 day Medicare coverage ends residents are immediately discharged . The regulations do not allow facilities to preemptively issue notice to evict a resident on the basis that they might not receive payment in advance when the Medicare coverage period ends. The facility Notice of Involuntary Discharge Policy documents that it is the policy of (NMS) that 30 days prior to the last covered day of service, where payment has not been made in advance (and third-party coverage is ending), a resident will receive notice of intent to involuntarily discharge the resident. Recent examples of this noncompliance include: 1. Review of the medical record revealed that Resident #8 was receiving services with Medicare as a primary payer and with a secondary payer documented in the medical record. Although care and services for Resident #8 were being paid for, the facility inappropriately issued a notice to the resident that he/she would be involuntarily discharged for nonpayment. The notice was issued on 11/29/16. Review (on 1/22/17 at 4:30 PM) of assessments transmitted into the Federal database revealed that resident #8 was then discharged about 30 days later on 1/3/17. 2. Review of the medical record revealed that Resident #5 was receiving services with Medicare as a primary payer and with a secondary payer documented in the medical record. Although care and services for Resident #8 were being paid for, on 11/11/16 the facility inappropriately issued a notice to the resident that he/she would be involuntarily discharged for nonpayment. Review of the medical record on 1/18/17 revealed that resident #5 was then discharged on [DATE]. Facility Administration failed to ensure effective systems to identify and address problem prone areas when the facility developed and implemented policies to knowingly engage in resident dumping practices in violation of State and Federal regulations. 3. Review of the medical record revealed that Resident# 2 was admitted to the facility in July 2016 for rehabilitation and possible long-term care. On 8/11/16 the Nurse Practitioner noted the resident had impaired judgment and on 8/30/16 the physician reported the resident was evaluated for capacity. The physician noted that Resident #2 lacked capacity to make decisions and had poor understanding of the choices he/she makes. Review of a complaint (MD 035) on 1/18/17 revealed an allegation that the facility staff transferred Resident #2 to the hospital for evaluation of an acute condition and then refused to accept the resident back to the nursing home because the resident owed the facility money. This concern was substantiated. Review of the medical record revealed that on 8/11/16 the resident was issued a 30 day notice of pending involuntary discharge. Although the practice is noncompliant, by policy the facility issues these notices preemptively when the facility believes there may be refusal by residents or their family members to pay for services in advance after the Medicare benefit period expires. The facility Notice of Involuntary Discharge Policy last revised 12/1/13 directs that it is the policy of (NMS) that 30 days prior to the last covered day of service, where payment has not been made in advance (and third-party coverage is ending), a resident will receive notice of intent to involuntarily discharge the resident. Review of the nursing home medical record revealed that Resident #2 was sent to the hospital on [DATE] and consistent with regulatory requirements, the facility documented in the medical record that the resident was expected to return to the facility. A hospital progress note dated 11/2/16 reported the resident was cleared for discharge backed to the nursing home on 10/29/16. However, on 10/29/16 at 13:12 the hospital case manager documented that he/she contacted the nursing home regarding the resident ' s return and was told the bed was no longer available. The case manager further noted that facility staff advised the resident had an outstanding balance and blamed the family for not cooperating with applying for Medicaid. However, review of the nursing home record revealed that the nursing home had not provided sufficient discharge planning assistance to the family. On 10/31/16 the hospital case manager was notified that the resident was by then ready for discharge. Upon contacting the facility ' s liaison the case manager was told the resident would not be able to return to the facility due to the outstanding balance. Review of hospital case management notes revealed that after the nursing home transferred the resident to the hospital and refused to accept the resident back, the hospital social service staff provided the discharge planning services which the nursing home had not. Hospital social service staff assisted the resident ' s responsible party to obtain power of attorney designation to be able to access the resident ' s financial accounts. With nursing home policy in place to demand advance payment, the hospital record documented in an 11/2/16 note that the RP had sent a check to the facility and the facility still refused to accept the resident back until they received the check and could verify that it was the amount (he/she) owes. Another hospital progress note dated 11/16/16 reported the resident was still stable for discharge and that the nursing home was still refusing to readmit the resident indicating that they had not received documents needed to apply for Medicaid. Working with families of nursing home residents on the Medicaid application process is however the responsibility of the nursing home. An 11/18/16 hospital social services note indicated that the hospital social services staff was able to secure level of care (approval) for Maryland Medicaid funding for Resident #2. Hospital social service staff then was able to secure a secondary payer to satisfy the nursing home demand that payment be secured before accepting the resident back. On 12/7/16, when the facility was notified that the hospital had arranged for insurance authorization, the Administrator still refused to accept the resident back and demanded to have a meeting with the son first. The hospital record documented CM explained patient needs to go if (the authorization) is obtained and they still insisted on meeting the son and CM. Hospital social service staff coordinated filing the application for Maryland Medicaid which the resident did qualify for. The resident was then sent to another nursing home after the hospital provided all of the discharge planning services necessary to meet the needs of Resident #2. During an interview with the Staff #1 on 1/17/17 at 10:05 he/she was asked why the resident was not accepted for readmission. Staff #1 stated the facility attempted to assist the resident ' s family member in completing an application for Medicaid so that the resident could continue his/her stay at the facility, but the family member did not cooperate. No documented evidence supported this was accurate and the family member in fact cooperated fully when offered discharge planning assistance in the hospital. In interview with the surveyor on 1/17/17 at 11:25 AM the Administrator stated there was a meeting at the hospital to discuss the application for Long-Term Care Medical Assistance. The meeting was attended by the Administrator, the facility ' s attorney, a hospital social worker and case manager. The Administrator stated they discussed how much money the resident owed the nursing home and that during the 6 weeks the residen