Every finding on record at Complete Care at Wheaton

Based on record reviews and interviews it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNAs) were provided with annual performance evaluations and skills competencies. This was found to be evident for 4 (GNA #9, #10, #11, #13) out of 5 GNAs reviewed for performance evaluations and skills competencies reviewed during the recertification and complaint survey. The findings include: During a review of employee files conducted on 04/16/26 at 11:42 AM it was discovered that GNAs #9, #10, #11, and #13 did not have documentation of a current annual performance evaluation and skill competencies. During an interview conducted on 04/17/26 at approximately 10:00 AM the Regional Director of Operations (RDO)# 8 reported that the facility has had recent changes in the Human Resource department and Staff Educator/ Assistance Director of Nursing (ADON). As a result, the facility had been unable to locate the performance evaluations and skills competencies. The RDO stated that this is an opportunity to identify an area of improvement.During an interview conducted on 04/17/26 at approximately 10:30 AM the Director of Nursing (DON) reported that she recently held a skills clinic with return demonstration for GNAs. The Surveyor requested the documentation for GNA #9, #10, #11, #13, and #26 skill competencies. The DON returned on 04/17/26 at approximately 11:30 AM with GNA #26's employee file and skill competencies. She stated that the GNA skill clinic did not go so well that although it was mandatory GNAs elected not to attend. The DON also stated that next year will be better. The DON further reported that she would provide skill competencies for GNAs #9, #10, #11, and #13.As of exit date on 04/21/26 the DON had not provided the Surveyor skill competencies for GNA #9, #10, #11, and #13.

Based on observation and staff interviews, it was determined that the facility failed to properly store and label medications. This was evident in 1 of 1 medication room and 2 of 2 medication carts observed during the recertification survey process.The findings include:On 04/15/2026 at 1:49 PM during an observation conducted with Licensed Practical Nurse (LPN) #20 in the East Wing 1 medication room, the following was observed:Two bags of Heparin (30,000 units/1000 mL Normal Saline) labeled for Resident #8 were stored in the medication room refrigerator. Review of the pharmacy labels revealed use-by dates of 02/27/2026 and 03/02/2026; both medications were observed beyond their labeled use-by dates.One bag of Heparin (30,000 units/1000 mL Normal Saline) labeled for Resident #8 was observed stored on a shelf in the medication room. Review of the medication label indicated that refrigeration was required; however, the medication was not stored in accordance with labeled instructions.One vial of Tuberculin Purified Protein (5 IU/0.1 mL) was observed opened without a documented date of opening, making it unable to determine the appropriate use period and stability after opening.On 04/15/2026 at 1:55 PM during an observation conducted with LPN #20 of the East Wing 1 medication cart, the following was observed: Aspirin 81 mg (1 bottle), Pain Relief (Tylenol) 325 mg (1 bottle), Senna-Plus (1 bottle), Tylenol Regular Strength 325 mg (1 bottle), and Risperidone Oral Solution 1 mg/mL (1 bottle) were opened without documentation of the date opened. On 04/15/2026 at 2:09 PM during an interview, LPN #20 stated that medications are required to be labeled with the date upon opening. LPN #20 confirmed that the above-mentioned medications were opened without a documented date, making it unable to determine when the medications were opened. On 04/15/2026 at 2:15 PM, during an observation conducted with LPN #21, of the East Wing 2nd medication cart, the following was observed: Folic Acid 400 mcg (1 bottle), Zinc 50 mg (1 bottle), Geri-Kot 8.6 mg (1 bottle), Non-Aspirin Extra Strength (1 bottle), Iron (Ferrous Sulfate) (1 bottle), Bisacodyl 5 mg (1 bottle), and Probiotic (1 bottle) were opened without documentation of the date opened. On 04/15/2026 at 2:22 PM during an interview, LPN #21 stated that bottle medications are required to be labeled with the date upon opening. LPN #21 confirmed that the observed medications were opened without a label indicating the date of opening.

Based on record review and interview, it was determined that the facility failed to ensure completion of required Preadmission Screening and Resident Review (PASARR) prior to admission. This was evident for 1 of 1 resident reviewed (Resident #14).The findings include:Preadmission Screening and Resident Review (PASARR) is a federal requirement that ensures individuals with serious mental illness or intellectual disabilities are evaluated prior to nursing home admission to determine appropriate placement and services. A Level I PASARR is an initial screening to identify potential need, and a Level II PASARR is a comprehensive evaluation required when the Level I screen is positive.On 04/15/2026 at 11:00 AM, this surveyor conducted a record review of Resident #14's Level I PASARR screening, completed on 03/09/2026, which indicated the need for a Level II PASARR evaluation. Resident #14 was admitted to the facility on [DATE]; however, record review revealed no documentation of a completed Level II PASARR in the resident's chart.On 04/15/2026 at approximately 11:15 AM, continued record review of the Social Services assessment dated [DATE] documented No in response to whether the resident was considered by the state Level II PASARR process to have a serious mental illness and/or intellectual disability, despite the Level I screening indicating the need for further evaluation.On 04/16/2026 at approximately 12:00 PM, this surveyor requested documentation of the Level II PASARR screening for Resident #14; the facility was unable to provide evidence that the screening had been completed.On 04/20/2026 at 10:55 AM, this surveyor conducted an interview with Admissions staff, who reported that PASARR screenings are expected to be completed prior to admission, typically by the hospital. She further stated that if a resident is admitted without a completed PASARR, the facility is responsible for ensuring completion, and that identification of a required Level II PASARR should occur within 24-72 hours of admission.On 04/20/2026 at 11:53 AM, this surveyor conducted an interview with the Administrator, who acknowledged that the facility accepted Resident #14 without verifying completion of the required Level II PASARR and stated that this had been overlooked. It was communicated that accepting a resident prior to completion of the PASARR process is a concern. The Administrator acknowledged and confirmed understanding.

Based on observations, record review, and interviews it was determined the facility failed to provide an activities program to meet the needs and preferences for 1 resident. This was evident for 1 (Resident #36) of 1 resident reviewed for activities during the recertification survey and complaint survey.The findings include:On 04/15/2026 at 02:18 PM, an observation was made of Resident #36 laying in bed with the TV pushed against the back wall behind the headboard of their bed. There were no other forms of activity or engagement observed in the resident's room.On 4/17/2026 at 11:53 AM, observed Resident #36 resting in bed and tv was pushed back against the wall. No other forms of activity or engagement were observed in the room. On 04/17/2026 at 12:16 PM, a review of Resident #36 documented activities in their medical record for a 30 day look back revealed the Resident was documented as watching TV for all the days except for 3/28/2026.Care plans provide direction for individualized care of the residents. A care plan is a guide that holistically addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 4/20/2026 at 8:57 AM, a review of Resident #36's care plan showed the resident's preferred activities were socializing with other residents and staff on a daily basis, drinking hot tea, and socializing during the coffee klatch program.Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons.MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's condition.Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function of a resident and is a required screening tool used in the nursing homes to assess cognition. A score of 13-15 points indicates intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition.On 04/20/2026 at 12:52 PM, a review of Resident #36 medical records revealed the Resident had multiple medical problems that included but were not limited to dementia and palliative care. A review of the Minimum Data Set (MDS) with an assessment date of 04/06/2026, confirmed Resident #36 had a score of 2 out of 15 on the Brief Interview of Mental Status (BIMS) indicating severe cognitive impairment.During an interview conducted on 04/17/2026 at 1:31 PM, the Surveyor and Activity Director reviewed Resident #36's documented 30-day period of activities which showed TV watching as the only activity with the exception of 03/28/26. The Activity Director confirmed that the Resident was not a TV viewer. When asked what type of 1:1 activities the Activity Department had to offer residents, the Activity Director stated that her activity assistants would go around to the resident rooms and offer a variety of 1:1 and independent activities based on different types of mental stimulation. The Surveyor discussed the concern that Resident #36 had not received the care planned activities. The Activity Director acknowledged that the resident had not received activities based on their assessed preferences and cognitive abilities. On 04/21/2026 8:06 at AM, an interview with the Nursing Home Administrator (NHA) confirmed that Resident #36 does not watch TV and can become agitated if it is pulled away from the wall in and in the resident's sight. Discussed concerns with NHA that the Activity Department had documented watching TV as the primary activity offered to Resident #36 for 29 days out of 30 days that were reviewed.

Based on record reviews and interviews, it was determined the facility failed to maintain Quality of Care. This was evident for 1 (#8) out of 1 Resident evaluated for quality of care during the recertification survey.The findings include:Necrotic refers to the death of cells or tissues, usually appearing as black, brown, or discolored hardened skin (eschar) or wet, sloughing tissue. Gangrene is a serious, potentially fatal condition involving tissue death (necrosis) caused by infection or lack of blood flow. Symptoms include skin discoloration (blue/black/red), pain, numbness, and foul-smelling blisters. Treatment requires immediate medical attention, often antibiotics, surgery to remove dead tissue, or amputation, alongside hyperbaric oxygen therapy.During a review of Medical Record for Resident #8 on 4/20/2026 at 1:35 PM a Nurse Practitioner Progress note written on 2/16/2026 was discovered which reported, noted necrotic toes on second and third toes on left foot - Vascular surgery consult.A Vascular Surgery consult progress note written on 2/19/2026 was found that reported Left second toe discoloration: May be dry gangrene but palpable pedal pulse. No need for further vascular workup with no correctable vascular lesion and Recommend podiatry consultation.An order was placed for a Podiatry consult on 2/26/2026. The order for Podiatry consult was signed off on the Treatment Administration Record on 2/27/2026. There was no documentation of a podiatry referral or consult being completed in the medical records for Resident #8 for the months of February or March.Continued medical record review for Resident #8 revealed a Nurse Practitioner progress note dated 4/08/2026 which reported the Wound Nurse Practitioner on 4/07/2026 documented stable dry gangrene eschar of left second and fifth toes and left lateral foot with palpable pulse and recommended Vascular evaluation and added the Vascular Surgery provider was reconsulted who made a recommendation for a podiatry consult.Further review of the medical records revealed a physician progress note on 4/09/2026 that reported New warmth, swelling, and light drainage of fifth toe and diagnosed cellulitis. It also identified left foot gangrene with eschar on the second, fifth toes and left lateral foot with palpable pulse. An additional order to Schedule Podiatry consult for 2nd and 5th toe discoloration was written on 4/09/2026. Further medical record review it was discovered that the Podiatrist assessed Resident #8 on 4/14/2026 and recommended the Resident go to the emergency room for further evaluation. Additional medical Record review showed that Resident #8 was transferred to the hospital for significant gangrenous changes to left foot per Podiatrist recommendation. He/she was admitted to the hospital for gangrene of the foot.Osteomyelitis is a serious, often bacterial infection of the bone, causing pain, swelling, and fever.Further medical record review of the hospital records showed the Resident had multiple toes that appeared gangrenous and x-rays were obtained which showed soft tissue swelling with no osteomyelitis, but antibiotics were given as a precaution. A surgical consult note reported the resident had stable dry gangrene to left foot and had no signs of infection right now. Podiatry evaluated the Resident in the hospital and did not recommend any surgical intervention.During an interview with the Transportation Coordinator #27 on 4/20/2026 at 2:49 PM she reported that she handled appointment scheduling and arranging transportation to the appointment. She reviewed the schedule log and found Resident #8 had an appointment with the Podiatrist on 4/09/2026 at 9:45 AM and was unable to find any additional Podiatry Appointments requested or made for Resident #8. During an interview with the Director of Nursing (DON) #2 on 4/20/2026 at 4:10 PM she reported that the only documentation found for Resident #8 having a podiatry consult completed was on 4/09/2026. She confirmed that she did not find any documentation for the consultation occurring in February or March. During an interview with Unit Manager #17 on 4/20/2026 at 4:36 PM he reported that if there were orders for a Resident was referred to have a consult with another doctor. The process would be for the Nurse who saw the order and confirmed the order would place the referral request on the Communication Board in the computer. The Transportation Coordinator would then schedule the appointment and transportation. He reported that he was not sure what happened to the referral order, but it didn't look like the process was followed through. During an interview with DON #2 on 4/21/2026 at 7:07 AM she reported the order for Resident #8 looked like it had been missed. She reported she would check to see if a referral had been made to a Podiatrist that would provide on-site healthcare services to the Resident through the HealthDrive Cooperation. During a review of the HealthDrive Podiatry Group Schedule on 4/21/2026 at 9:31 AM it was confirmed that Resident #8 had not been seen by the HealthDrive Podiatrist during the months of February and March.

Based on observation and interviews it was determined that the facility failed to ensure staff perform appropriate hand hygiene. This was evident for 1 Licensed Practical Nurse (LPN #21) of 1 LPN observed for hand hygiene during the recertification survey and complaint survey.The findings include:Hand hygiene is mandatory before putting on gloves and immediately after removing gloves to prevent cross-contamination, as gloves are not a substitute for hand hygiene. Health care workers must change gloves and perform hand hygiene when moving from a soiled to a clean body site on the same patient, or between patient contacts. The proper terms for putting on medical gloves are donning and taking off medical gloves is doffing.An observation of Resident #2's wound care was conducted on 4/20/2026 at 1:34 PM. The Surveyor observed LPN #21 provide wound care for the Resident. During the wound care observation the LPN removed the old bandage from the wound and then changed gloves however the LPN failed to perform hand hygiene between glove changes. The LPN cleansed the wound and proceeded to pack the wound without changing gloves between the cleansing of the wound and applying the clean dressing. The LPN failed to change gloves when she moved from a soiled to clean procedure. During the continued observation LPN #21 failed to perform hand hygiene when she donned a new pair of gloves after the wound care was completed. The LPN removed the old bandage on the next wound and changed gloves however she failed to perform hand hygiene between the glove change. The LPN cleaned the wound, removed her gloves and failed to perform hand hygiene before donning a new pair of gloves to place the clean dressing and bandage on Resident #2s wound. On 04/20/2026 at 3:19 PM, an interview with LPN #21 confirmed she did not perform hand hygiene between glove changes. On 04/20/2026 at 3:51 PM, the findings of the observation were reported to The Director of Nursing and the Nursing Home Administrator.

Based on surveyor record review, interviews with facility staff and Residents, it was determined that the facility failed to revise Resident care plans and conduct timely care plan meetings. This was found to be evident in 4 (Resident #10, 41, 93, and 106) out of 4 Residents reviewed for timing and revision of care planning. The findings include: 1) On the initial tour of the facility 03/31/2025 at 09:58 AM Resident #10 stated that he/she remembered attending one care plan meeting last summer and does not recall having received invitations for care plan meetings. Resident stated, I have been here for 2 years. A care plan is a document that outlines a person's healthcare or support needs, how those needs will be met, and by whom. It serves as a roadmap for providing consistent and effective care. The care plan helps organize and prioritize caregiving activities, ensures continuity of care, and promotes collaboration among healthcare providers. It is a vital tool for effective and personalized care. It ensures that individuals receive the right support, at the right time, and from the right people, ultimately improving their well-being and quality of life. The surveyor conducted a record review of Resident #10's medical record on 04/02/2025 at 09:30 AM. During the review of the medical record, it revealed that there were two care conference notes in the progress note section of the electronic medical record dated 05/22/2024 and 12/19/2024. Both care conference notes indicated that Resident #10 and his/her son attended the care conferences. However, there were no meetings held for February of 2024, August of 2024 and March of 2025. Additionally, there was a care plan attendance sheet located in the miscellaneous section of Resident #10's electronic medical record dated 12/19/2024 with Resident's signature on the sheet. There were no other care plan attendance sheets located in the electronic medical record for Resident #10 for the past year. In an interview with the Licensed Nursing Home Administrator (LNHA) on 04/02/2025 at 10:08 AM the surveyor requested care plan attendance sheets and care plan meeting notes for the past year for Resident #10. At 11:05 AM, the LNHA provided the surveyor with the care conference note and attendance sheet for 12/19/2024 and stated that was all the documentation that was found. In an interview with the Regional Social Worker on 04/03/2025 at 11:10 AM the surveyor conveyed to the Regional Social Worker that the only care plan meeting documentation for the past year was for December of 2024 for Resident #10. The Regional Social Worker stated that she would investigate this. On the follow-up interview with the Regional Social Worker at 12:30 PM on 04/04/2025 she provided the surveyor with the care conference notes for 05/22/2024 and 12/19/2024 and the care plan attendance sheet for 12/19/2024 for Resident #10. The Regional Social Worker acknowledged that there was no additional documentation on care planning meetings for the past year for Resident #10. The surveyor asked the Regional Social Worker what the expectation was for the care plan meeting process. The Regional Social Worker stated that written invitations were mailed to the Resident Representatives and given to the Residents, the attendance sheets were maintained in the miscellaneous section of the electronic medical record and the care plan meeting note was documented in the progress note section of the electronic medical record. 2) The surveyor conducted a record review of Resident #93's medical record, specifically the care plan on 04/02/2025 at 10:06AM. Review of Resident #93's care plan revealed that Resident had a care plan for anticoagulant therapy (blood thinner) dated 08/28/2024 with a revision on 09/11/2024 and a target date of 05/30/2025. Review of the physician orders revealed that there was no current physician order for anticoagulant therapy for Resident #93. According to the discontinued orders for Resident #93, the anticoagulant therapy (Lovenox) was discontinued on 10/15/2024. The surveyor interviewed the Regional Clinical Nurse Consultant (RCNC) at 09:50 AM 04/07/2025 regarding Resident #93's care plan and anticoagulant therapy. The surveyor conveyed to the RCNC that Resident #93 had a current care plan for anticoagulant therapy and that there was not a current physician order for an anticoagulant medication and that the anticoagulant medication was discontinued 10/15/2024. The RCNC reviewed Resident #93's physician orders and care plan and acknowledged the surveyor. The RCNC stated that Resident #93 was no longer receiving an anticoagulant medication (Lovenox), the medication was discontinued on 10/15/2024, and the care plan should have been resolved. A low air loss mattress (LAL) is a medical-grade mattress designed to prevent and treat pressure injuries by reducing moisture and health buildup. The LAL mattress uses a system of inflated air cells that continuously circulate air, providing a dry, comfortable sleeping surface that delivers consistent pressure redistribution. Pressure ulcers are injury to the skin and underlying tissue resulting from constant and prolonged pressure on the skin. This pressure can lessen blood flow to the affected area, which may lead to tissue damage and tissue death. Venous ulcers (stasis ulcers) are open wounds on the leg or ankle caused by abnormal or damaged veins due to poor circulation and high pressure in the veins. Arterial ulcers (ischemic ulcers) are painful skin wounds caused by poor blood circulation and inadequate blood supply to the lower extremities. 3) The surveyor conducted a review of Resident #41's medical record on 04/07/2025 at 08:10 AM. Review of Resident #41's medical record revealed that Resident #41 had a physician order for a low air loss mattress (LAL). Further review of the medical record revealed that Resident had care plans for pressure ulcers, arterial ulcers, venous ulcers and skin impairment that were resolved but remained on the current care plan. Review of the current physician orders for Resident #41 revealed that there were no treatment orders for any ulcers. In addition, Resident #41 had a care plan for an antiplatelet medication (inhibits blood clots), but review of Resident #41's physician orders revealed that there was not a current order for antiplatelet medication. In an interview with the Director of Nursing (DON) at 11:05 AM on 04/07/2025 the surveyor conveyed to the DON that Resident #41 had a care plan for an antiplatelet medication but did not have a physician order for an antiplatelet medication. The DON reviewed Resident #41's physician orders and care plan and acknowledged that Resident did not have an order for an antiplatelet medication but had a care plan for antiplatelet medication. The surveyor conducted an interview with the East Wing Nurse Unit Manager (UM) on 04/07/2025 at 12:55 PM. During this interview, the surveyor conveyed to the UM that Resident #41 had care plans for pressure, arterial and venous ulcers and these care plans were resolved but remained on the current care plan, and that there were no physician orders for wound treatment for these ulcers. The UM acknowledged the surveyor and confirmed that Resident #41 did not have any ulcers at present and all previous ulcers were healed, and that the care plan should have been revised to reflect Resident #41's current skin condition. No additional information was provided by the facility at the time of exit. 51491 Care Plan meetings are meetings with a team of care providers including the attending physician, a registered nurse with responsibility for the resident, a nursing assistant with responsibility for the resident, a member of food and nutrition services, the resident, and the resident ' s representative if applicable to ensure the care plan is continually adjusted to meet the changing needs or concerns of residents. Care Plan meetings are required to be held quarterly. 4) During a telephone interview with the family of Resident #106 on 4/03/25 at 5:31 PM he/she reported having difficulty scheduling Care Plan Meetings with the Interdisciplinary Team. During a review of Resident #106 Electronic Medical Records (EMR) on 4/04/25 at 07:45 AM it was discovered that Resident #106 was admitted to the facility on [DATE] and discharged on [DATE]. The following Care Plan meetings were found in the EMR. On 11/16/23 a Care Plan Meeting was held. The sign-in sheet shows the attendees were the Social Worker, Director of Rehab, Nursing and family members. On 2/08/24 a Care Plan Meeting was held. The sign-in sheet shows the attendees were the Director of Rehab, Activities Director, Ombudsman, Registered Dietician, Unit Manager and family members. On 5/17/24 a Care Plan Meeting was scheduled but the family did not attend. The facility planned to reschedule. There were no additional Care Plan meetings documented. During an interview with the Regional Social Worker on 4/09/25 at 2:28 PM, the social worker was notified of the limited documentation of Care Plan Meetings and attendance rosters for Resident #106. She reported Care Plan meetings are done quarterly and would expect a Care Plan Meeting note to be documented along with an attendance sign in sheet to be scanned into the EMR when the Care Plan meeting occurred. She stated if the documents are not in the EMR, maybe they are in medical records and not uploaded yet. She advised she would attempt to find additional Care Plan documentation. During an interview with the Regional Social Worker 4/10/25 at 11:13 AM the Social Worker reported she was unable to find any additional Care Plan documentation for Resident #106.

Based on interviews and medical record review, it was determined that the facility failed to invite a resident to their care plan meeting. This was evident in 1 (Resident#35) of 7 residents reviewed for care planning. The findings include: On 03/31/25 at 10:55 AM Resident #35 informed the surveyor that he/she was not invited to and did not attend care plan meetings. On 04/02/25 at 08:26 AM a review of Resident #35's medical record revealed that the resident was admitted to the facility on [DATE] and care plan meetings were held on 1/30/25, 2/5/25 and 2/26/25. Resident #35 attended one care plan meeting on 1/30/25. However, the resident did not attend care plan meetings on 2/5/25 and 2/26/25. The records failed to reveal that the resident was notified. On 04/03/25 at 10:43 AM in an interview, the Regional Social Worker stated it was the practice of the facility to invite residents and their responsible parties in writing to care plan meetings. Further, she would check the records to ascertain whether Resident #35 was invited. On 04/03/25 at 10:43 AM The Regional Social Worker notified surveyor that she could not locate documented evidence to show that Resident#35 was informed of care plan meetings for February 2025. On 04/03/25 at 10:50 AM the Nursing Home Administrator and the Regional Clinical Nurse Consultant were notified of the surveyor's findings.

Based on surveyor record reviews and facility staff interviews, it was determined that the facility failed to offer the opportunity to complete an advance directive and provide educational materials on advance directive for Residents and/or Resident Representatives. This was found to be evident for 3 (Resident #41, 93 and 95) out of 3 Residents reviewed for advance directives. The findings include: An advance directive is a legal document that specifies a person's wishes for end-of-life healthcare. It also specifies who should make healthcare decisions on your behalf if you are unable to do so yourself. On 03/31/2025 at 11:43 AM the surveyor conducted a record review of Resident #93's medical record. During the review of Resident #93's medical record, specifically the social services assessment and documentation - V6 forms dated 8/30/2024 and 11/20/2024, it revealed documentation that Resident #93 did not have an advance directive in place, and the opportunity to complete an advance directive was not offered and advance directive educational materials were not provided for Resident #93 or Resident Representative. The surveyor interviewed the Regional Social Worker at 11:10 AM on 04/03/2025. During this interview the surveyor conveyed to the Regional Social Worker that Resident #93 did not have an advance directive as documented on the August and November 2024 social services assessments. Additionally, the social services assessments indicated that the opportunity to complete an advance directive was not offered and educational materials for advance directive were not provided for the Resident #93 or Resident Representative. The Regional Social Worker acknowledged the surveyor. The surveyor conducted a record review of Resident #41's medical record on 03/31/2025 at 01:52 PM and it revealed that Resident #41 had a social services assessment and documentation - V6 form dated 04/08/2024. This social services assessment indicated that Resident #41 did not have an advance directive in place, and the opportunity to complete an advance directive was not offered and educational materials for advance directive were not provided for Resident or Resident Representative. The surveyor interviewed the Regional Social Worker at 11:10 AM on 04/03/2025. During this interview the surveyor conveyed to the Regional Social Worker that Resident #41's social service assessment in April of 2024 revealed that Resident did not have an advance directive on file, and that the opportunity to complete an advance directive was not offered and educational materials for advance directive were not provided for Resident #41 or Resident Representative. The Regional Social Worker acknowledged the surveyor. On 04/02/2025 at 12:45 PM the surveyor conducted a record review of Resident #95's medical record. Review of the medical record for Resident #95 revealed that the social services assessment and documentation - V6 form completed 11/21/2024 indicated that Resident #95 did not have an advance directive in place. Further review of the social services assessment indicated that the opportunity to complete an advance directive was not offered, and educational materials regarding advance directives were not provided for Resident #95 or Resident Representative. In an interview with the Regional Social Worker on 04/03/2025 at 11:10 AM, the surveyor conveyed to the Regional Social Worker that Resident #95 did not have an advance directive in place according to the documentation on the social services assessment dated [DATE], and the opportunity to complete an advance directive was not offered and educational materials regarding advance directives were not provided for Resident #95 or Resident Representative. The Regional Social Worker acknowledged the surveyor. In a follow-up interview with the Regional Social Worker on 04/04/2025 at 12:30 PM the surveyor confirmed with the Regional Social Worker that the documentation revealed that Residents #41, 93 and 95 did not have advance directives in place, and that these Residents or Resident Representatives were not offered an opportunity to complete an advance directive and were not provided educational materials for advance directives.

Based on review of facility investigation, record review, and interview, it was determined that the facility failed to ensure that a resident remained free of abuse. This was evident for 1 (Resident #105) of 31 abuse investigations reviewed during the survey. The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facility's plan and action were verified during this survey; therefore, this deficiency was found to be past noncompliance with a compliance date of 3/11/24. The findings include: On 4/2/25 at 9:00 AM, a review of the Facility- Reported incident MD00203253 revealed that on 3/5/2024 at 12:30 PM, Geriatric Nurse Assistant (GNA #8) reported to the Nursing Home Administrator (NHA) and alleged Licensed Practical Nurse (LPN #6) of grabbing Resident #105's arm and hitting him/her on the face. On 4/3/24 at 7:45 AM, a review of Resident #105's medical records revealed a BIMS (Brief Interview for Mental Status: an assessment used in nursing homes and other long-term care facilities to monitor cognition) score of 0 out of 15 on 12/27/2023, which meant severe impairment. A care plan that was initiated on 3/27/2023 indicated, has potential to be verbally and physically aggressive related to Dementia. Dementia is a general term for the gradual decline in memory, thinking and other cognitive functions that can significantly impact daily life. On 4/3/24 at 8:23 AM, a review of the facility's investigation revealed that the alleged incident happened on 2/29/24 around 1:30 PM. However, the allegation was reported to the NHA on 3/5/2024 at 12:30 PM. The following interviews from the involved staff were conducted: On 3/5/2024 at 12:20 PM, GNA #8 reported to the NHA that on 2/29/24 he/she responded to assist GNA #7 who was giving care to Resident #105. The resident started yelling and became agitated. LPN #6 came to the room to assist, however, the resident hit LPN #6. GNA #8 stated that he/she and GNA # 7 witnessed LPN #6 grab and pinch the left hand and slapped Resident #105 on the forehead. On 3/5/24 at 12:31 PM, GNA #7 stated that on 2/29/24, while giving care to Resident #105, the resident started yelling and shouting, GNA #8 and LPN #6 came to assist. However, the resident hit the LPN #6 on the chest and then he/she grabbed Resident #105's hand and hit him/her in the face. On 3/6/24, LPN #6 stated that he/she did not abuse Resident #105 and only raised his/her hands and then grabbed the resident's hands and told him/her to stop the aggressive behavior. On 4/3/2025 at 11:05 AM, the surveyor reviewed and verified the corrective measures the facility implemented in response to the 2/29/2024 incident: 1. The alleged employee and witnesses were immediately suspended pending investigation a. LPN #6, who was the alleged perpetrator was placed on administrative leave pending investigation. He/she was terminated on 3/10/24. b. GNA #8 was disciplined for failing to immediately stop and report the alleged abuse per facility policy and education. He/she was suspended from 3/5 to 3/9/24 and received education handling aggressive behaviors with NHA on 3/10/2024. c. GNA #7 was disciplined for failing to immediately stop and report the alleged abuse per facility policy and education. He/she stated, I was scared to report and didn't know it. He/she was suspended from 3/5 to 3/9/2024 and received education handling aggressive behaviors with NHA on 3/9/24. 2. Interviews were obtained from the involved staff. 3. 17 other Staff members were also interviewed, and no issues were reported. 4. The Resident Representative was notified on 3/5/24 at 12:30 PM. 5. The Local Law Enforcement was notified on 3/5/24 at 12:40 PM. 6. The Ombudsman was notified on 3/5/24 at 1:30 PM. 7. Skin assessment was conducted. 8. Other Residents on the unit were unable to be interviewed, thus, head to toe skin assessments were completed for each resident with no negative findings. 9. The Social Worker visited Resident #105 on-3/5/24. 10. The Psychiatrist visited the Resident on 3/19/24. 11. Abuse education was conducted on 3/8/24, which was attended by 10 staff members and on 3/9/24 which was attended by 9 staff members. 12. The incident was reported to the Maryland Board of Nursing on 3/11/2024 and confirmed receipt on 3/11/2024. On 4/4/25 at 8:21 AM, in an interview with the NHA, he described that as soon as an allegation of abuse was identified, the facility suspended the involved staff and started the investigation. He added that other residents and staff members were also interviewed, a one on one education to the involved staff members as well as house wide education was also conducted. On 4/4/25 at 10:08 AM, during an interview with GNA #9, he/she stated that the facility expected the staff to immediately report any kind of abuse to the administrator. He/she added that he/she had received online and regular classroom abuse trainings. On 4/4/25 at 10:10 AM, in an interview with LPN # 4, he/she stated that the staff had a couple of hours to 24 hours to report an abuse to the Unit manager, the Supervisor or the Administrator. He/she added that he/she had received abuse trainings either in classroom or on videos. On 4/9/25 at 12:23 PM, during an interview with the NHA, the [NAME] President of Operations and the Regional Clinical Nurse Consultant, the surveyor informed them that Resident 105's incident was considered Past Non- Compliance.

Based on staff interviews and medical record review, it was determined that the facility failed to provide written notification for Residents that were transferred to the hospital. This was found to be evident for 3 Residents ( #4, #18, #48) out of 3 Residents reviewed for hospitalization. The findings include: During medical record review for Resident #48 on 04/04/25 at 11:15 AM. It was revealed that the resident was transferred to the hospital on 4/2/24, 8/27/24 and 8/28/24, the facility did not provide written notification to the resident or the resident ' s representative regarding the reason for the transfer to the hospital. During continued records review on 04/04/25 at 12:57 PM Resident ' s #4 record review revealed resident was transferred to the hospital on 5/18/24, 6/18/24 and 2/16/25 with no evidence that the facility provided written notification and reason for transfer to resident or resident's representative during transfer to the hospital. During an interview with the Regional Clinical Nurse Manager (RCNM) on 04/04/25 at 1:00 PM regarding written notification to residents and/or their representatives about the reason for transfer or discharge to the hospital. The RCNM confirmed that the facility did not have a process in place for providing such notifications. The surveyor informed the RCNM of this concern, and he acknowledged the concern. A review of the nurse ' s note for Resident #18 was conducted on 04/09/25 at 08:13 AM. The note, dated 03/30/25 at 8:49 PM, stated Resident was in bed sleeping with no apparent distress. No further emesis noted. [Resident's family member] came to visit, as [resident's family member] said [resident's family member] was called earlier about the resident. The resident ' s [family member] stated [resident's family member] wanted the resident transferred to the hospital. Writer explained the interventions in place, but [resident's family member] insisted the resident be taken to the hospital. [Resident's family member] called 911; they arrived at approximately 3:05 PM and transported the resident to HCH [Holy Cross Hospital] at 3:16 PM. An interview conducted on 04/09/25 at 10:09 AM with License Practical Nurse (LPN) #1 regarding the process for transferring a resident to the hospital, LPN #1 stated, I will notify the physician for orders, prepare a transfer package which includes the face sheet, MOLST [Maryland Order for Life Sustaining Treatment] form, recent labs, medication list, and complete transfer assessment. I will also provide a copy of the transfer notification to the resident or the resident ' s representative. After the resident leaves, I will call the hospital for updates. The surveyor asked LPN #1, What is the process if a family member calls 911 LPN #1 responded, It ' s the same process. During the continued medical record review on 04/09/25 at 10:11 AM for Resident #18, there was no evidence of written documentation indicating that the reason for the hospital transfer was provided to the resident or their family representative. During an interview with the RCNM regarding hospital transfers on 04/09/25 at 10:30 AM, he acknowledged that no written documentation was provided to the residents (#4, #18, and #48) during the transfer. The surveyor informed the RCNM of this concern.

Based on facility staff and Resident interviews and surveyor record review, it was determined that the facility failed to provide written notification of the bed hold policy for a Resident that was transferred to the hospital. This finding was found to be evident for 1 Resident (#95) out of 1 Resident reviewed for hospitalization. The findings include: A Bed Hold is the act of holding or reserving a Resident's bed while the Resident is absent from the facility for therapeutic leave or hospitalization. It must be provided to all facility Residents regardless of payment source. The Bed Hold policy should be disclosed in the admission packet during an initial admission to the facility and it should be disclosed to Resident/Resident Representative at the time of transfer. On 04/01/2025 at 07:40 AM during the tour of the nursing unit, the surveyor interviewed Resident #95. Resident #95 stated that he/she had a recent hospitalization due to stomach collapse. The surveyor reviewed Resident #95's medical record on 04/03/2025 at 07:03 AM and the review revealed that Resident #95 transferred to the hospital on [DATE] (an emergency room visit) and 02/04/2025 (inpatient). The surveyor did not locate any documentation that Resident #95 or Resident Representative received written notification from the facility of the bed hold policy for Resident #95's transfer and admission to the hospital on [DATE]. Further review of Resident #95's medical record revealed that on admission to the facility, the Resident signed an admission packet dated 10/10/2024 which indicated that if Resident #95 should be hospitalized , he/she would be consulted at that time as to whether he/she would choose to hold the bed at the facility. In an interview with the Licensed Nursing Home Administrator (LNHA) and the Regional Clinical Nurse Consultant on 04/03/2025 at 09:55 AM the surveyor asked what the procedure was for written notification of bed hold policy when a Resident was transferred to the hospital. The Regional Clinical Nurse Consultant stated, I know what you are asking for but the facility does not provide written notification of the bed hold policy for Residents when they transfer to the hospital. No additional information was provided by the facility at the time of exit.

Based on record review and interview, it was determined that the facility failed to conduct an accurate Preadmission Screening and Resident Review (PASRR). This was found evident for 1 (Resident #27) out of 1 resident reviewed for PASRR screening. The findings include: According to the Centers for Medicare and Medicaid (CMS), the Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long-term care. Furthermore, Congress developed the PASRR program to prevent inappropriate admission and retention of people with mental disabilities in nursing facilities. Federal law mandates that Medicaid-certified nursing facilities (NF) may not admit an applicant with serious mental illness (MI), mental retardation (MR), or a related condition, unless the individual is properly screened, thoroughly evaluated, found to be appropriate for NF placement, and will receive all specialized services necessary to meet the individual's unique MI/MR needs. If a resident tests positive for a Level I, they are then evaluated in depth, called ' Level II ' PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care. On 04/01/25 at 10:02 AM, a record review for Resident #27 ' s PASRR Level 1 showed that in section D, all of the answers were checked No. The document stated that if all answers in part D are ' No ' , the individual must be referred to AERS [Adult Evaluation and Review Services] for a Level II Evaluation. There was not a PASRR Level II found in this Resident ' s record. On 04/02/25 at 12:45 PM, an interview was conducted with the Social Worker. Resident #27 ' s PASRR was reviewed with the Social Worker. This surveyor asked, based on the results of the PASRR, if she would expect this Resident to have had a PASRR Level II Screening. She reported that the mental disorders that this Resident has do not require him to need a PASRR Level II. She confirmed that the Resident ' s PASRR Level I was not filled out correctly, as it should not have been indicated that he/she needed a PASRR Level II.

Based on medical record review and staff interviews, it was determined that the facility failed to revise a care plan. This was evident for 3 (#4, #48, and #445) out of 3 residents reviewed for care plans. The findings include: A review of a Nurse ' s note for Resident #4 was conducted on 04/02/25 at 12:43 PM. The note dated 03/04/2025 at 16:07 stated Writer went to assess the patient after receiving a verbal call from a caregiver that the patient was on the floor. Observed patient sitting near the bed and wheelchair with no visible injury. The patient denied pain upon assessment. No swelling or skin discoloration noted. The patient had a light scratch on [resident ' s gender] left side, not related to the fall but sustained while using the bathroom. The patient self-transferred from the floor to the bed. A care plan is a comprehensive, individualized plan of care developed for each resident. It outlines the residents ' medical, psychological, emotional, and social needs, as well as the goals, interventions, and services required to meet those needs. Care plans are created and maintained by the interdisciplinary care team. During continued medical record review on 04/02/25 at 1:14 PM, the care plan was not updated following the resident ' s fall on 03/04/25. An actual fall care plan was not initiated or revised. The original care plan was initiated on 08/05/2024, with the last revision also documented on 08/05/2024. A Gastrostomy tube (G-tube) is a flexible tube inserted through the skin and abdominal wall directly into the stomach to provide nutrition, fluids, and medications when an individual is unable to consume adequate nutrients orally. During a medical record review conducted on 04/03/25 at 7:30 AM, it was revealed that Resident #48 was transferred to the hospital on [DATE], 04/02/24, and 08/27/24 for gastrostomy tube (G-tube) dislodgement and replacement. However, there was no documentation indicating that a care plan for G-tube dislodgement and replacement was initiated or updated. On 04/03/25 at 12:24 PM, during an interview with the Assistant Director of Nursing/Infection Control Preventionist/Staff Educator (RN) (ADON/ICP). The surveyor inquired about the process and expectations for care plan revisions following G-tube dislodgement and replacement. The ADON/ICP further explained that care plans are to be updated whenever there is a change in the resident ' s condition, when concerns arise, as needed, and on a quarterly basis. Additionally, the ADON/ICP clarified that all members of the interdisciplinary team are responsible for updating the care plan in response to any changes in the resident ' s condition. The Unit Manager is responsible for ensuring that all changes are accurately reflected in the care plan. The ADON/ICP further confirmed that updates should be made immediately following any such changes. On 04/03/25 at 1:10 PM, the surveyor informed the Administrator and the Regional Clinical Nurse Manager of concerns regarding the revision of the care plan. During medical records review on 04/09/25 at 7:30 AM Resident #445 had a witnessed fall on 12/16/24, as documented in staff statements. However, there was no evidence that a fall-specific care plan revision was initiated or documented.

Based on record review and facility staff interview, the facility failed to 1) assess a Resident with an actual fall and 2) document a witnessed fall. This was evident for 1 (resident #445) of 1 resident reviewed for quality of care. The findings include: A fall is defined as an unintended descent to the floor or other lower surface, with or without injury to the resident or patient. This includes slips, trips, or loss of balance, whether witnessed or not, and whether or not the individual is able to get up without assistance. A fall assessment is a systematic process used by healthcare professionals to identify a patient's risk of falling and to determine contributing factors. It typically involves evaluating medical history, medications, cognitive status, mobility, gait, balance, and environmental risks. The goal is to guide the development of individualized interventions to prevent falls and improve patient safety. A nursing care plan is a structured, written document that outlines the nursing care to be provided to a patient, tailored to their specific healthcare needs and goals. It serves as a comprehensive guide for nurses, detailing the assessment, diagnosis, interventions, and outcomes related to the patient's health status. Nursing care plans are dynamic documents that evolve as the patient's condition changes, allowing for ongoing assessment and modification of the care provided. During a medical record review conducted on 4/19/25 at 7:30 AM, it was revealed that Resident #445 experienced a witnessed fall on 12/16/24. The resident ' s medical record revealed no documentation of an incident report related to the fall, post-fall assessment and revision or update to the resident ' s fall care plan to reflect the incident and resident condition. During an interview with the Regional Clinical Nurse Manager (RCNM) on 4/9/25 at 11:43 am, the RCNM acknowledged that fall assessments were required to be completed following resident falls. However, he confirmed that in the reviewed case, the facility did not complete the required fall assessment, nor was the resident ' s care plan revised to reflect the fall incident.

Based on surveyor observation, facility staff interviews and surveyor record review it was determined that the facility failed to follow appropriate respiratory care and services. This finding was found to be evident in 1 (Resident #93) out of 1 Resident reviewed for respiratory care and services. The findings include: On tour of the East Wing Nursing Unit on 03/31/2025 at 11:49 AM the surveyor observed Resident #93 with oxygen in use. There was an oxygen humidifier bottle and oxygen tubing attached to the oxygen concentrator and an oxygen cannula in Resident #93's nostrils. The surveyor did not observe an oxygen usage sign on the Resident door or on the doorframe of Resident #93's room. The surveyor conducted a record review of Resident #93's medical record on 04/02/2025 at 10:30 AM. The record review revealed that Resident #93 had physician orders for oxygen and to change the oxygen humidifier bottle tubing every Thursday on the night shift. Further review of the medical record revealed that Resident #93 had a care plan for oxygen therapy related to respiratory illness. In addition, the surveyor reviewed the facility's oxygen administration policy dated 03/14/2023 and revised 09/12/2024 from The Compliance Store policy platform that was provided by the Director of Nursing (DON) on 04/10/2025 at 09:07 AM. The policy guidelines were to place an oxygen warning sign on the Resident's room door where oxygen was in use, change the oxygen tubing/cannula weekly and as needed, and change the oxygen humidifier bottle when empty or every seventy-two hours. The surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) on 04/10/2025 at 11:55 AM and reviewed Resident #93's oxygen usage and the facility's oxygen administration policy. The surveyor asked the ADON/IP what the expectation was for oxygen signage and changing oxygen tubing and humidifier bottles when oxygen was used for Residents. The ADON/IP stated that the oxygen tubing and humidifier bottles were to be changed weekly on the night shift, and that she was not aware of the posting of oxygen signage where oxygen was in use. The ADON/IP further stated that the facility does not place oxygen signs on the Residents' rooms where oxygen was in use. The surveyor conveyed to the ADON/IP that item #6 on the facility's oxygen administration policy indicated that oxygen warning signs must be placed on the door of the Residents' rooms where oxygen was in use. ADON/IP acknowledged the surveyor that item #6 on the facility's policy for oxygen administration indicated that oxygen warning signage must be placed on the Resident's room door where oxygen was in use. No additional information was provided by the facility at the time of exit.

Based on review of employee records and staff interview, it was determined that the facility failed to complete annual performance reviews for Geriatric Nursing Assistants (GNAs). This was evident for 2 (#10, #17) out of 5 GNA staff members reviewed during the annual survey. The findings include: Performance evaluations are to be completed once every 12 months to identify in-service education needed to address competencies of the geriatric nursing assistants. On 04/08/25 at 1:44 PM, a review of GNA #10 and GNA #17's employee records revealed that no performance reviews for 2023 and 2024 were included. On 04/09/25 at 11:59 AM, an interview conducted with the Nursing Home Administrator (NHA) confirmed that annual GNA performance evaluations for 2023 and 2024 had not been done for GNA #10 and GNA #17. At the time of exit conference, the facility did not provide any additional evidence to show that performance evaluations for 2023 and 2024 were completed for GNA #10 and GNA #17.

Based on observation of medication administration, medical record reviews, and staff interviews, it was determined that the facility licensed staff failed to maintain a medication error rate of less than 5 percent for 2 out of 2 residents ( #94 and #81). This finding was evident for 3 out of 26 opportunities observed for errors which resulted in a medication error rate of 11.54%. The findings Include: 1) On 04/02/25 at 8:20 AM, during a medication administration observation for Resident #94, the surveyors observed Licensed Practical Nurse (LPN) #1 administer scheduled medications to the resident. The medications included 1 tablet Amlodipine 10 mg (milligram). LPN #1 stated, I am holding the Amlodipine due to the resident ' s heart rate of 59 and I will contact the physician. 2) During medication administration on 04/02/25 at 8:52 AM for Resident #81, the surveyors observed Licensed Practical Nurse (LPN) #1 administer scheduled medications to the resident. The surveyors observed LPN #1 administer 1 drop of Brimonidine Tartrate Ophthalmic Solution 0.2% to the resident ' s right eye. During the continued medication administration observation, the LPN #1 stated that she was unable to administer Cholecalciferol 25 mcg (microgram) because it was not available . During medication administration reconciliation, on 04/02/25 at 9:30 AM, following medication administration, Resident #94 ' s April 2025 Medication Administration Record (MAR) was reviewed. The review revealed that there was no physician order to withhold Amlodipine 10mg heart due to a 59 bpm (beats per minute). Additionally, LPN #1 documented the medication as administered, despite having stated that it was to be withheld. On 4/2/25 at 10:05AM Resident #81 ' s April 2025 Medication Administration Record (MAR) was reviewed . The review revealed that Cholecalciferol 25mcg (Vitamin D) was documented as administered, although the medication was not available at the time of the observation. On 4/3/25 at 11:00AM during the continued medication administration reconciliation for Resident #81. The physician's order stated to instill 1 drop of Brimonidine Tartrate Ophthalmic Solution 0.2% (Brimonidine Tartrate) in both eyes three times a day for glaucoma. However, the surveyors observed LPN #1 instill 1 drop in the right eye only. During an interview on 04/03/25 at 12:07 PM, the surveyor asked LPN #1 about the process for medication administration when medication is not available. LPN #1 stated, I will call the pharmacy to send the correct dose, notify the physician, and document in the MAR using 'indicate 7' to show that the medication is not available. Sometimes I check in the Pyxis first, but most of the time, I call the pharmacy. LPN #1 confirmed that the eye drop was administered to the right eye only and that she used nursing judgment to hold the Amlodipine due to a low heart rate of 59. The surveyor informed LPN #1 that during medication reconciliation, both Vitamin D and Amlodipine were documented as administered. LPN #1 responded, I thought I documented '7' (which indicates 'not given'). I ' m sorry, I will fix it. The LPN #1 advised that the Amlodipine was administered later that day after speaking with the Nurse Practitioner (NP). On 04/03/25 at 12:50 PM, the surveyor notified the Nursing Home Administrator (NHA) and the Regional Clinical Nurse Manager (RCNM) regarding the medication error, and both acknowledged the concern.

Based on observation, staff interviews and record review, it was determined that the facility failed to properly store medications. This was found to be evident in 2 of 2 medication storage rooms and 3 of 3 medication carts observed during the recertification survey. The findings include: During a medication cart observation conducted on 04/07/25 at 9:17 AM of the [NAME] Wing (Cart #2) with Licensed Practical Nurse (LPN) #14, the following were observed, two Tylenol tablets and 1 Vitamin tablet were found stored in a medication cup inside the cart. LPN #14 stated that the resident initially requested the medications but later refused them and asked for Oxycodone instead. Further observations of the medication cart revealed an open, used and undated Basaglar 100-unit insulin pen, twelve 12 loose pills, 10 individually packaged Spiriva Handi Haler 18 mcg (microgram) capsules that were not labeled with a resident ' s name, and 1 individually packaged Ondansetron 4 mg (milligram) tablet also not labeled with a resident ' s name. On 04/07/25 at 9:25AM, the surveyor interviewed LPN#14 about the process for handling medications refused by a resident and the process of disposing of medications. LPN #14 stated, I will notify the physician, document the refusal, and discard the medication in a trash can. During the Medication administration reconciliation review conducted on 4/7/25 at 9:30AM, the Medication Administration Record (MAR) for April 2025 confirmed that Oxycodone was administered at 7:27 AM to Resident ' s #121. During an observation of the Camelot wing medication cart conducted on 04/07/25 at 9:44 AM, the surveyors and LPN #2 observed 2 loose brown oval tablets, 1 opened and undated bottle of Active Liquid Protein, and 1 opened and undated bottle of Vitamin C. During an interview conducted on 04/07/25 at 9:48 AM , the surveyor asked LPN #2 to explain what the facility ' s policy was for labeling a bottle of medication. The LPN stated, The process is to date bottles upon opening. LPN #2 confirmed that the bottles of Active Liquid Protein and Vitamin C had been opened but not dated. During the medication cart observation for the East Wing conducted on 04/07/25 at 10:08AM, the surveyors and LPN #13 observed 7 loose tablets found in the medication cart. The surveyors and LPN #13 observed 1 bottle of MiraLAX, 3 bottles of Robitussin, 1 bottle of mouthwash, 1 container of Aspercreme opened and undated. Further observation of the medication cart revealed 1 bottle of Liquid Morphine and 1 bottle of Liquid Lorazepam each belonged to expired resident #90. On 4/7/25 at 10:10:08AM, during an interview with LPN #13, the surveyor inquired about the process for handling medications belonging to discharged or expired residents. The LPN#13 stated that typically, two nurses crush the medications and place them in a Ziplock bag, which is then given to the Unit Manager. The Director of Nursing (DON) is usually responsible for disposing of narcotics. On 04/07/25 at 10:33 AM during the observation of the East Wing Medication Storage room with the Unit Manager LPN UM #5, medications that belonged to residents #90 and #18 were found in an open gray pharmacy bag on the bottom shelf of a metal rack. The drug buster medication disposal system deactivates and contains the active chemicals in unused OTC and prescription medications, preventing misuses, abuse and contamination. During an interview with Unit Manager #5 conducted on 4/7/25 at 10:33AM he stated that the process for handling medications of discharged or expired residents was to remove the medications from the cart and return them to the pharmacy. The Unit manager #5 noted that the pharmacy delivers medications daily, and depending on the delivery personnel, they may also collect returns. The Unit Manager #5 further confirmed that the expectation for refused medications that were not a narcotic should be crushed and flushed. For narcotics 2 licensed nurses must destroy the narcotic with the use of a drug buster. During an observation in the [NAME] Wing storage room on 4/7/25 at 10:51 AM with Unit Manager LPN #3, 1 bottle of enteral feeding formula (Nepro with CarbSteady) was observed to be expired (use before 1 Sep 2023). The refrigerator temperature log was missing signatures for three consecutive days (4/3/25, 4/4/25, 4/5/25). The Unit Manager LPN #3 admitted failure in monitoring and documentation. On 4/7/25 at 10:55AM, during an interview with Unit Manager #3, she stated that the process for disposing of medications for discharged or expired residents involves returning the medications to the pharmacy. Unit Manager #3 confirmed that the pharmacy delivers and collects medications daily. Additionally, Unit Manager #3 acknowledged that monitoring and documenting refrigerator temperatures is the responsibility of the nursing staff but stated, I guess they are not doing it. LPN #3 further confirmed that it is the responsibility of both the nurses and the unit manager to routinely check the medication storage room for expired medications and expired enteral feeding products. During an interview with the Regional Clinical Nurse Manager (RCNM) on 04/07/25 at 11:08AM, the surveyor inquired about the process for disposing medications and returning them to the pharmacy. The RCNM confirmed that the expectation is to dispose of non-narcotic medications by discarding them, while narcotic medications are destroyed using a Drug Buster by two licensed nurses. The RCNM also confirmed that the pharmacy picks up return medications during deliveries but was uncertain about the frequency of these pickups. Additionally, the RCNM acknowledged that the facility policy states all unused, contaminated, or expired medications must be disposed of in accordance with state laws and regulations, and that prescription drugs may not be flushed down the toilet, per EPA guidelines. The concerns observed were shared with the RCNM, who acknowledged them and stated that an in-service will be conducted for staff.

Based on interviews and medical record review, it was determined that the facility failed to ensure that residents who required dental services on a routine basis, received the necessary services in a timely manner. This was evident for 1(Resident#59) of 1 resident reviewed for dental services. The findings include: Resident #59 was admitted to the facility on [DATE] with diagnoses including Dementia, and Cognitive Communication Deficit. On 03/31/25 at 09:36 AM Resident#59 informed the surveyor that he/she experienced pain when chewing food. On 04/03/25 at 10:36AM a review of Resident# 59's clinical record revealed that the resident had not seen a dentist since admission to the facility on [DATE]. On 04/07/25 at 08:20 AM the surveyor observed Resident #59 for 25 minutes eating breakfast. The resident took small bites and at the end of the 25 minutes had consumed one slice of toast, one half bowl of Oatmeal and one serving of Cheerios. Resident #59 stated that he/she experienced pain in the right jaw while chewing the toast. On 04/07/25 at 08:49 AM in an interview the Registered Dietitian (RD) stated that Resident #59 was interviewed recently on 01/31/25 regarding concerns for weight loss and at that time, the resident did not mention any dental pain. 04/07/25 at 09:26 AM the surveyor informed the Regional Clinical Nurse Consultant (RCNC) and the NHA of the findings. After the surveyor's intervention on 04/07/25, the physician ordered medications to address the resident's oral pain. An oral health evaluation was completed on 04/07/25 at 10:18AM by Unit Manager Staff #3 and it revealed that Resident #59 had 1-3 decayed or broken teeth. On 4/10/25 at 10:06 AM the RCNC informed the surveyor that an appointment was scheduled for Resident #59 to see a Dentist on 04/12/25.

Based on surveyor observation(s), review of clinical records, facility policies and procedures, and resident and staff interview(s), it was determined that facility staff failed at the time of admission to accurately assess a cognitively impaired resident's risk for elopement, and failed to assess the cognitively impaired resident's safe smoking risk (Resident #102). The facility staff also failed to prevent repeated episodes of unsafe resident smoking within the facility when identified, and failed to maintain smoking materials in a secured environment. These failures resulted in 6 of 6 residents being at risk for accidents/hazards. (#102, #100, #21, #57, #86, and #113). These failures resulted in an immediate jeopardy (IJ) being identified on 05-24-19 at 9:40 AM related to a resident's risk for elopement (Resident #102). On 05-24-19 at 5:36 PM, the facility staff submitted an IJ removal plan related to the elopement to the Office of Health Care Quality (OHCQ) which was accepted. On 05-29-19 at 1:00 PM a second IJ was determined related to the omission of a smoking risk assessment, and unsafe resident smoking practices (Residents #102, #57, #21, #100, #86, and #113). On 05-29-19 at 11:51 PM, the facility staff submitted an IJ removal plan for safe smoking evaluations and safe resident smoking practices to the OHCQ which was accepted. Both immediate jeopardies were removed on 5/31/19 at 12:15 PM after confirmation that the accepted plans had been fully executed. After removal of the immediacy, the deficient practice remained at a scope and severity of E. The findings include: 1. During investigation of facility reported incident #MD 450, on 05-24-19, review of the clinical record for Resident #102 revealed that the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. However, review of the elopement assessment tool revealed that the admitting nurse (Nurse #6) failed to accurately assess the resident's cognitive status which resulted in a lower risk score which indicated the resident was not at risk for elopement. In addition, Nurse #6 documented, on 04-18-19 at 7:59 PM, that Resident #102 was not oriented to time, not oriented to place, had short and long-term memory problems, and was unable to recall after 5 minutes. Nurse #6 did not incorporate the pertinent observations made while completing the nursing admission assessment into the elopement evaluation. As a result, the resident was not identified as being at risk for elopement, and Resident #102 eloped from the facility the following morning (04-19-19.) This cognitively impaired resident was located by facility staff in the company of a police officer blocks away from the facility. Review of the facility investigation revealed a written statement by a geriatric nursing assistant (GNA) #11. In the statement, GNA #11 wrote that, on 04-19-19 between 7:45 AM and 8:15AM, Resident #102 informed the staff member twice that he/she was going out to smoke. Surveyor also reviewed a written statement by Nurse #7 which stated on 04-19-19 at 9:20 AM, he/she had a conversation with Resident #102 in the resident's room. The resident also expressed intent to go out to smoke to Nurse #7. A written statement, dated 04-19-19, by the facility's admission concierge stated that family members were leaving the building from visiting. Resident #102 walked out when visitors were exiting the building. A nurse's note, dated 04-19-19 at 3:51 PM, written by Nurse #7 read, patient is status [REDACTED]. Patient received in bed in stable condition. Had breakfast served, after which he/she verbalized that he/she wanted to go out and smoke in the smoking area. The nurse's note went on to state that, at approximately 10:00 AM, Nurse #7 went to administer medication to Resident #102 and was unable to locate the resident on the nursing unit. Facility staff then began a search on and off facility property to locate the resident. Resident #102 had wandered away from the facility after expressing an intent to go out to smoke to both GNA #11, and Nurse #7. On 05-22-19 at 1:33 PM, interview with Nurse #6 revealed he/she had completed an elopement risk assessment, based solely on a conversation held with the resident. Nurse #6 did not utilize the information provided to the facility in the hospital discharge summary which diagnosed the resident with cognitive impairment. That [DIAGNOSES REDACTED].#102 being identified as being at risk for elopement. Although there was evidence in the clinical record that the facility staff used pertinent information that had been provided in the hospital discharge summary to complete admission documentation for Resident #102, Nurse #6, upon interview, did not explain why some of the discharge summary information was used during the admission process (i.e. list of medication) for Resident #102 and some of the discharge summary information was omitted (i.e. [DIAGNOSES REDACTED]. On 05-23-19 at 5:45 PM, interview with the 3-11 shift supervisor (Nurse #10) revealed that he/she reviewed the information in the admission packet both prior to, and at the time of Resident #102's admission to obtain admitting orders from the attending physician. Nurse #10 also informed the surveyor that the admission packet was uploaded into the computer prior to resident #102's arrival by the facility admissions department staff to allow the physician and facility staff to review pertinent medical information about the resident before the resident arrived at the facility. Nurse #10 stated that the discharge summary was received electronically immediately prior to the resident's arrival, and a paper copy of the discharge summary arrived with the resident. Nurse #10 stated that the discharge summary was used by the attending physician to provide admission orders [REDACTED]. Staff #10 also informed the surveyor that Nurse #6 was responsible for the head to toe assessment on Resident #102, and that he/she (staff #10) was present during the assessment to determine the need to obtain further orders from the attending physician. However, there was no discussion between the two nurses about the [DIAGNOSES REDACTED].#102 a score of 10 on the elopement risk evaluation tool. A score of 10 on the elopement risk evaluation would have identified the resident as being at risk for elopement. Staff #10 stated that residents identified as being at risk for elopement would have interventions implemented to keep them safe to include a wanderguard bracelet which would alert staff of the residents attempt to exit the building. Because Resident #102 was not identified as being at risk for elopement, those interventions were not implemented, and the resident wandered out of the building without staff awareness. On 05-28-19 at 9:00 AM, surveyor interviewed the admissions concierge who wrote the statement dated 04-19-19 to determine who the family members were that Resident #102 exited the building with. The admissions concierge at that time informed the surveyor that he/she did not witness Resident #102 leaving the facility with family members as the written statement indicated, and in actuality did not witness Resident #102 exiting the building on the morning of 04-19-19 at all. In the presence of a second surveyor, the admissions concierge was again asked if he/she had witnessed Resident #102 leaving the building as the written statement indicated. The admission concierge hesitated in responding, so surveyor repeated the question, did you see Resident #102 leaving the building. The admission concierge then responded, No, I did not see him/her leave the building. Surveyor then asked the admission concierge, why did you provide this statement? (allowing the admissions concierge to see the written statement titled employee/witness interview listing the admissions concierge as the person providing the statement). The admissions concierge responded, The director of nursing told me to write it. On 05-28-19 at 10:00 AM, the director of nursing and the corporate consultant were informed of the admission concierge's allegation that he/she was instructed to write the statement which indicated that Resident #102 was witnessed exiting the building with family members. The director of nursing neither confirmed nor denied the admission concierge's allegation that he/she was directed by the DON to write the statement and provided no additional information. On 05-24-19 at 9:40 AM, an immediate jeopardy (IJ) was determined for resident's safety related to the facility staff's failure to accurately assess Resident #102's elopement risk, resulting in the resident's elopement from the facility. On 05-24-19 at 3:22 PM, the facility staff submitted the IJ removal plan which included the following measures taken: -on 04-19-19 resident #102's elopement risk assessment was revised to reflect cognitive impairment and implemented interventions (wanderguard bracelet, photo of the resident at the front reception area, and psychological physician evaluation) to prevent further elopement; -Nurse #6 was in-serviced 04-22-19 on elopement assessment accuracy and the importance of reviewing hospital medical records; -The elopement assessment tool was revised to include the words cognitive impairment next to Alzheimer's/Dementia on the tool; -100% of active licensed nurses were in-serviced between 04-19-19 and 04-24-19 on the accurate method of elopement assessment utilizing the tool and reviewing the hospital medical records; -On 04-22-19, the administrator audited all active residents to verify the accuracy of the existing elopement assessments. Any discrepancies were corrected immediately by the assistant director of nursing. -The removal plan also stated to ensure compliance, the supervisor/manager on duty, audits all new admissions and readmissions from 04-19-19 forward to ensure accurate elopement assessments were done by the charge nurse and reflective of the hospital medical records. Audits consist of checking the elopement risk assessment, checking the hospital records and assessing the resident. This audit was completed on 04-24-19. -Finally, the removal plan addressed Quality Assurance Performance Improvement by stating that the director of nursing or the assistant director of nursing will audit all new admissions for the accuracy of elopement risk assessment on a weekly basis. The results of the audits will be submitted to the QAPI committee monthly. The QAPI committee will determine if any additional interventions are needed at the end of the three-month period. On 05-31-19 at 12:15 PM, the administrator and director of nursing were notified that the surveyors had verified that the removal plan had been fully implemented, and the immediacy was removed. Additionally, during review of facility reported incident #MD 450, and further review of the clinical record for Resident #102 on 05-29-19, revealed that the facility staff did not complete a smoking assessment on the newly admitted Resident #102 prior to the resident leaving to smoke unsupervised. Surveyor review of the clinical notes, written on 04-19-19, revealed that Resident #102 informed the charge nurse (Nurse #7) that he/she was going out to smoke after breakfast. At the time of the resident's expressed intent to go smoke, no safe smoking evaluation had been completed to determine if the resident was safe to smoke independently or required staff to be in attendance to ensure safety. Resident #102, with a [DIAGNOSES REDACTED].#7 and geriatric nursing assistant (GNA) #11 he/she was going to do) unattended. The resident eloped during that smoke break. A smoking evaluation was completed on 04-19-19, after the resident's return, which determined Resident #102 was a dependent smoker (requiring supervision to smoke). A policy, titled Safe Smoking Policy for Cadia [NAME]land Facilities Where Smoking is Permitted with a revision date of 01-22-19 included the following statements: The facility shall designate a specific area or areas where residents may smoke. Smoking shall not be permitted on facility property outside of designated smoking areas. The facility shall make reasonable efforts to secure resident smoking materials such as: cigarettes, cigars, lighters, lighter fluids, pipes etc. it shall be the facility's responsibility to secure these materials when they are not in use and make them accessible to residents who wish to smoke during appropriate/designated times. Residents who smoke and/or their responsible parties shall be presented with a form advising them of the facility's policy with respect to securing smoking materials. Signed copies of these forms shall be maintained in the residents ' medical record. Review of the facility's safe smoking policy on 05-24-19 revealed no reference to when safe smoking evaluations would be completed, or who would be responsible for completing safe smoking evaluations in a timely manner. (prior to allowing residents to smoke independently) As a result, on 05-24-19 at 1:20 PM, interview with Nurse #7 revealed that he/she did not know who completed safe smoking evaluations upon admission and was not sure where resident #102's safe smoking evaluation could be located in the clinical record. On 05-24-19 at 1:40 PM, interview with the social worker revealed that he/she was solely responsible for doing safe smoking evaluations in the facility. The social worker also stated that, if residents were admitted when the social worker was not in the building, the safe smoking evaluation(s) would not be completed until his/her return. On 05-24-19 at 2:30 PM, interview with the director of nursing provided no additional information. 2) On 05-23-19, review of the clinical record for resident #100 revealed a physician's progress note, dated 04-29-19. The attending physician documented the patient was found smoking in the room. The clinical record also revealed psychologist progress notes, dated 05-01-19, which documented, addressed resident regarding reported smoking in the building On 05-24-19 at 11:00 AM, interview with the attending physician revealed that he/she did not observe resident #100 smoking in the room, but facility staff had reported the resident's smoking in the room on two separate occasions, which prompted the entry in the physician's progress note. A safe smoking evaluation for resident #100 conducted on 04-17-19 determined that the resident was a dependent smoker who requires supervision to smoke. A physician's orders [REDACTED]. A psychologist progress note, dated 05-01-19, documented that he/she addressed smoking in the building with resident #100, with the resident being defensive during the discussion, at first denying his actions though he had been observed by staff. Both physician notes documented that unsafe resident smoking occurred after the initial order instructing facility staff to check the resident's room for any smoking materials on 04-22-19. On 05-29-19 at 4:00 PM, interview with the facility social worker who completes all resident safe smoking evaluations in the facility revealed no additional information as to how resident #100 obtained the smoking materials when found smoking, despite staff checking the room each shift for the presence of smoking materials. 3). On 05-22-19 record review for resident #21 revealed smoking evaluations that were done on 12-09-18 and on 03-22-19. The evaluations determined that the resident was an independent smoker and required no supervision to smoke. It also revealed that resident #21 understood smoking materials were for use only in the designated smoking area and smoking materials were to be kept locked at the nurses' station or other secure location On 05-24-19 further review of the clinical record revealed a secure smoking materials acknowledgement form signed by Resident #21 on 05-01-19 that stated, facility will store all smoking materials in a secure location for residents who smoke. In addition, social worker documented on 05-02-19 that Resident #21 was known to go out and buy cigarettes for residents so he/she was educated on smoking policies. The social worker educated resident #21 that he/she must give smoking materials that he/she purchased on behalf of other residents to the receptionist so that they could be kept secured for the safety of all residents. Resident #21 agreed to sign the acknowledgement form and was informed of consequences (not specified) should he/she violate the safe smoking policy. On 05-24-19 review of a physician progress notes [REDACTED].#21 was giving cigarettes to other residents. The note also revealed the attending physician's awareness that the resident was going out and buying cigarettes for other residents as well. However, although Resident #21 continued to violate the safe smoking policy, there was no evidence that any further actions were taken to address the risk the resident's actions posed to the safety of others. On 05-21-19 at 11:56 AM, surveyor interview with resident #21 revealed that he/she smoked outside the facility (not in the designated smoking area) and kept cigarettes and lighter on his/her person. The resident then showed surveyor a pack of cigarettes and a lighter in his/her pocket at the time of the interview. Review of the plan of care for resident #21 revealed No smoking materials will be kept by the resident if deemed unsafe. On 05-22-19 at 10:00 AM, interview with staff #4 (who accompanies residents out to smoke and monitors the secured smoking container) confirmed that resident #21 bought and kept smoking materials on his/her person as stated during the resident interview. Staff #4 also confirmed that resident #21 bought cigarettes for other residents as well. On 05-23-19 at 11:07 AM surveyor interview with the administrator revealed that resident #21 was noncompliant with facility smoking policy. He/she kept smoking materials on person as well. The administrator stated she/he talked to the resident multiple times about the smoking policy including safety hazards for other residents, but the resident was noncompliant. On 05-24-19 at 3:51 PM, DON interview revealed Resident #21 was a safe and independent smoker but he/she was not allowed to keep smoking materials. On 05-28-19 at 11:52 AM, Resident #21 again showed the surveyor that he/she had a pack of cigarettes and a lighter in his/her pocket. In addition, on 05-22-19 at 10:00 AM, interview with Staff #4 confirmed that Resident #21 bought and kept smoking materials on his/her person as stated during the resident interview. Staff #4 also confirmed that Resident #21 bought cigarettes for other residents as well. Interview with Staff #2 on 05-28-19 at 1:20 PM revealed that neither safe or unsafe smokers were allowed to keep smoking materials on their person but were required to keep them secured with facility staff in one central location. According to Staff #2, Resident #21 was noncompliant with facility smoking policy. Although Resident #21 continued to violate the safe smoking policy, there was no evidence that any further actions were taken to address the risk the resident's actions posed to the safety of others. On 05-29-19 Resident #21 signed a behavior contract that stated, holding on to smoking materials is a violation of facility's guidelines for resident behavior and failure to comply with the guidelines may result in administration actions. 4.) On 05-24-19 surveyor review of the social worker's notes revealed that, on 10-30-18, resident #57 was assessed by the social worker as a dependent smoker due to body stance and inability to wheel himself/herself around. Further review of the social worker's notes revealed that, on 10-30-18, Resident #57 signed a Secure Smoking Materials Acknowledgement acknowledging that the facility staff were to store all smoking materials in a secure location, catalog them, and upon request, during scheduled smoking times, make these materials available to residents who signed the agreement. On 11-06-18, Resident #57 was re-assessed by the social worker for smoking and was determined to be a dependent smoker, (requiring supervision) with a need to wear a smoking apron. On 11-10-18, a nurse's note revealed that Resident #57's room had the smell of cigarette smoke coming from the room. The nurse and the supervisor recovered a pack of cigarettes from the resident's room at that time. On 03-20-19, a nurse's note revealed that Resident #57 was observed with an unlit cigarette in his/her mouth. The resident removed the cigarette from his/her mouth but refused to give it to the nursing staff. The note also revealed that the geriatric nursing assistant (GNA) who observed the resident with the cigarette in between his/her lips notified the nurse, who then notified the shift supervisor. The shift supervisor asked the resident for the cigarette and the resident refused to comply. The shift supervisor informed Resident #57 local law enforcement would be contacted if the resident lit the cigarette. The resident did not light the cigarette; however he/she was permitted by facility staff to return the unlit cigarette to his/her bag. There was no further documentation or evidence of follow up related to the cigarette known to be in the possession of this resident with unsafe smoking practices. On 04-13-19, a nurse's note for Resident #57 revealed that the unit hallway was filled with the smell of burning grass, but no cigarette was found on the resident. The resident was again educated not to smoke in their room. On 04-14-19, a nurse's note for Resident #57 revealed that, patient's room smelled like cigarettes. Writer did not see resident smoking. Writer and oncoming nurse asked resident to give up the cigarettes. Resident gave up the cigarettes and was reminded smoking was not allowed in resident rooms. On 04-15-19 a nurse's note for Resident #57 revealed resident room smelled of cigarette smoke. Writer did not see resident smoking. Writer tried to educate resident of the danger of smoking in the room. On 04-16-19, a nurse's note for Resident #57 at 07:54 AM revealed, resident room smells like weed/cigarette smoke. No cigarette noted in hand. Writer educated resident regarding the facility smoking rules and dangers of smoking in their room. On 04-16-19,a nurses note at 09:06 AM revealed, Resident #57 was noted smoking in his/her room approximately 07:30 AM. DON was made aware and tried to explain about not smoking in the room On 04-19-19, a nurse's note for Resident #57 revealed, writer smelled smoke in front of resident's room. Writer re-educated resident that it is not safe to smoke in their room as resident was found smoking in their room in the morning. On 04-19-19, resident was seen by the psychologist for aggressive behavior related to cigarette use in room on 04-16-19. Resident denied smoking in his/her room. Resident was explained that his/her actions were unacceptable and could have resulted in being discharged from the facility, as will acts of aggression. On 04-22-19, an attending physician's orders [REDACTED]. However, 04-22-19, a nurse's note for Resident #57 revealed, resident was noted smoking in their room at approximately 10:30 PM with half of the cigarette and ashes on the floor. Teaching was done and explained no smoking in room again about the smoking policy. Although Resident #57 continued to violate the safe smoking policy, there is no evidence that any further actions were taken to address the risk that the resident's actions posed to the safety of others. Despite a month of incidents involving unsafe smoking by Resident #57, the clinical record review revealed that the facility demonstrated no aggressive measures to ensure the safety of other residents jeopardized by this resident's continued non-compliance with safe smoking practice. There was only documented evidence of verbal counseling of the resident, and an order for [REDACTED]. On 04-25-19, a social worker's note revealed that facility would revoke smoking privileges if the resident was caught smoking in their room. On 05-01-19, a second Secure Smoking Materials Acknowledgement form was signed by the resident. On 05-02-19, the social worker documented a re-education of Resident #57 related to the facility smoking policy. However, on 05-05-19, a nurse's note for Resident #57 revealed that a cigarette was also found in resident's bed; teaching was done. On 05-06-19, an administrative note revealed that the administrator spoke with Resident #57 regarding the smoking policy. The administrator explained to the resident that smoking was allowed only in the designated smoking area and that no cigarettes or lighting materials will be kept by residents, but rather in the reception area, in a lock box. The administrator stated that the resident verbalized understanding. Although facility staff spoke to, and reeducated Resident #57 multiple times about the smoking policy, the resident continued to violate the safe smoking policy and there was no evidence that any further actions were taken to address the risk that the resident's actions posed to the safety of others. On 05-29-19 at 10:40 AM, surveyor interview with the administrator revealed that Resident #57 was in possession of two cigarettes which were allegedly obtained from a visitor and the resident voluntarily gave them to the Administrator to be saved for some other time. On 05-29-19 at 11:15 AM, during surveyor interview with Resident #57, the resident admitted having cigarettes in his/her possession earlier that morning, however, the resident informed the surveyor that the cigarettes were obtained from another resident who smokes, not a visitor. On 05-29-19 at 11:30 AM, surveyor observed resident smoking tobacco in the designated smoking area during the designated smoking time. On 05-29-19 at 1:00 PM, surveyor interview with the DON revealed that the resident had been unsuccessfully educated and re-directed several times. The DON stated the facility staff's issuing Resident #57 with a 30-day notice of discharge because of danger to self and others would be of no use as there is no safe discharge available for the resident to another facility or the community. However, there was no evidence in the clinical or administrative records to demonstrate the facility staff had made an effort to find placement for the resident elsewhere. On 05-29-19 at 1:15 PM, surveyor review of the form Notice of Violation of Guidelines or Resident Behavior revealed that the resident was issued this violation for holding on to his/her smoking materials and that the facility was taking the following administrative action: smoking privilege revoked. This form was signed by the administrator, the social worker, and the resident. On 05-29-19 at 1:30 PM, surveyor interview with the Administrator provided no additional information. 5) On 05-22-19 at 11:00 AM, surveyor interview with resident #86 revealed that he/she kept his own cigarettes and lighter since admission on 12-02-18. Resident #86 then proceeded to pull out a pack of cigarettes and a lighter from his/her pocket and showed it to the surveyor. Further review of the clinical record revealed that, on 12-18-18 and 5-02-19, Resident #86 signed a Secure Smoking Materials Acknowledgement that stated that the facility staff were to store all smoking materials in a secure location and give them to the resident during scheduled smoking times. Despite the signed agreement, there was no evidence that facility staff were monitoring for resident #86's compliance with the secure smoking materials acknowledgement forms that he/she previously signed. On 05-28-19 at 11:10 AM, surveyor interview with the administrator revealed that resident was a safe smoker and the facility keeps all his/her cigarettes and lighter. The administrator was unable to explain how resident #86 was in possession of the pack of cigarettes in his/her pocket on 05-22-19. The administrator reported that resident #86 subsequently turned in his/her cigarettes and lighter to facility staff on 05-22-19 after surveyor observation/intervention. The administrator stated that Resident #86 had never been observed smoking in his room or in an undesignated smoking area. f. On 05-22-19 at 11:00 AM surveyor observation in facility's therapy department revealed resident #113 was observed in therapy with a pack of cigarettes and a lighter on his/her person. Interview with the resident at that time revealed that the resident smoked in the facility's designated smoking area but keeps all smoking materials. Review of the clinical record for Resident #113 revealed that the resident was alert and oriented and able to verbalize his/her own needs. On 05-01-19 at 5:40 PM, documentation by the SW (Social Worker) #2 revealed a smoking assessment was completed that the resident could make their own decisions and was able to demonstrate safe smoking techniques through a smoking observation. The facility's determination, that was based on the 05-01-19 assessment, revealed that the resident was an independent smoker, who required no supervision to smoke. On 05-28-19 at 11:00 AM, interview with SW #2 revealed that residents' smoking assessments are completed by SW #2 usually within 48-72 hours at the time of the resident's admission/readmission. When the smoking assessment is completed, a determination of whether the resident is a dependent or independent smoker is indicated. When asked, SW #2 revealed that no other staff members conducted the smoking assessment at the time of resident's admission to the facility. On 05-28-19, further record review revealed that, on 05-01-19, Resident #113 signed a smoking contract (as indicated in the facility's smoking policy) that all smoking materials (lighters, matches, cigarettes, etc.) for residents who smoke, will be secured by the facility. This included that smoking materials are to remain in a secured location and catalog by the facility. On 05-29-19, review of the facility's 05-28-19 Smoking Material Check Log revealed that staff found Resident #113's smoking materials on his/her person. Further review of the 05-28-19 Check Log revealed that staff updated the resident's smoking plan of care to address the resident's non-compliance with the facility smoking policy to reflect having smoking materials in the room unsecured. The facility staff also obtained a physician's orders [REDACTED].#113 on the facility's smoking policy. On 05-29-19 at 12:30 PM, surveyor interview with the facility's administrator and the Director of Nursing (DON) revealed that on , 05-28-19, the resident's smoking materials were removed immediately by the facility staff and placed in the locked box, which is located at the facility's lobby/reception area Surveyor interview with Resident #113 on 05-29-19 at 1:00 PM revealed that the resident was educated by facility staff that a

Based on surveyor observations, review of the clinical records, review of the facility policy and procedures and interviews with facility staff and residents, it was determined that facility staff failed to ensure that residents were free from accident hazards when residents assessed at high risk for smoking hazards put all residents at increased risk for serious harm . This finding was identified for 4 out of 20 residents who were smokers in the facility. (#39, #62, #208, #65) On June 20, 2017 at at 12:45 PM, an Immediate Jeopardy for health and safety was determined by the State Office of Health Care Quality. The Immediate Jeopardy was abated on June 20, 2017 at 9PM, following the facility's implementation of corrective actions to ensure the health and safety of all residents who were at risk for serious harm from fire. The following is the facility's abatement plan developed on 06-20-17: a. Residents #39, #62 and #208 have had their care plans and assessments updated to address the dangers of unsafe smoking. Additionally, these residents have all been counseled on the facility's smoking policy and the requirements of supervision. Moving forward, all assessments will be done on admission, readmission, quarterly, annually and following any significant change. b. All residents have the potential to be affected. An audit was conducted by the Director of Nursing and Administrator to ensure that all smokers in the building were identified and have appropriate care plans in place to address safe smoking. A schedule has been put in place to ensure that a staff member is supervising smoking at designated times, and documented in the smoking policy and procedure, so that any resident identified as unsafe can be sure to have appropriate interventions in place. Department heads or designee will be assigned to monitor the smoking area. c. The facility has put into place a schedule to ensure that supervision is present in the smoking area for any resident that needs supervision when smoking. The door is secured so that unsafe smokers will not be able to gain access without supervision. The facility has also placed a sign on the door indicating when supervised smoking will occur. Director of nursing or designee will audit the schedule monthly to ensure the procedure is accurately being followed. The result of this audit will be reported to the QA (quality assurance) Committee. The code to the designated smoking area has been changed effective today. Maintenance director will be assigned to change the code monthly. Responsible parties of unsafe smokers have been notified of the designated smoking times. d. The Director of Nursing will audit the charts of 3 smokers per week to ensure that appropriate evaluations and care planning is done. The Administrator or Designee will physically assess the smoking area twice a shift, every day to ensure that no unsafe smokers are smoking unsupervised. Results of these audits will be reported to the QA Committee for a period of 3 months. The QA Committee will determine what, if any additional interventions, are required at the end of the three-month period. 1. On 06-20-17 at 9:15 AM, the surveyor observed Resident #39 while smoking in the designated smoking area. Resident #39 was not supervised and no apron (burn resistant apron for smokers) was in use. The resident's pants had burn holes and the inside of his/her finger tips had dried dark blisters. Resident #39 stated that the burn holes were from when he/she was on a different medication, and he/she kept falling asleep while smoking but that he/she was no longer on that medication. Further observation revealed that resident #39 threw the cigarette out to the grassy area when finished. The lit end of the cigarette was at the edge of the fingertips when the resident discarded it. Then he/she was observed returning to his/her room with his/her smoking materials after smoking. On 06-20-17, surveyor review of the facility's smoking policy and procedure revealed that, if a resident is identified as a dependent smoker and unsafe, the nurse will maintain the residents' cigarettes in the medication cart. Unsafe smokers will be given a smoking apron and will be accompanied by appropriate staff during scheduled smoking hours. In addition, residents assessed as dependent smokers are not to be left unsupervised while smoking, and other residents cannot provide supervision for residents deemed as dependent smokers. Surveyor review of the clinical record revealed a smoking assessment, completed on 01-06-17, which revealed that resident #39 was assessed as high risk and determined to be a dependent smoker under the facility policy, and should have the nurses maintain smoking materials, use an apron, and be supervised while smoking. Further review of the clinical record revealed a social service note, written on 01-06-17 as a late entry for 01-05-17, which stated that resident #39 was caught smoking in his/her room , that a behavior contract was initiated, that the resident would leave his/her lighter and cigarettes at the nursing station, be given a smoking apron, and receive staff supervision while smoking. In addition, surveyor review of a nursing concurrent review note, documented on 05-22-17, revealed that another resident who resides at the facility notified a staff member that resident #39 was smoking a foreign object in the smoking area. Surveyor review of the attending physician notes revealed that the physician documented the holes in resident #39's pants and burns on the fingers, and indicated that the resident was counseled, but that he/she refused to use the apron and gloves. Review of care plans for resident #39 revealed that they were not revised, nor did they reflect the individualized needs of resident #39. The care plan revealed interventions which included utilize smoking apron if indicated, smoking allowed only in designated smoking areas, complete smoking assessment on admission, re-admission, quarterly, annually, and with any significant change, and encourage compliance. The plans did not document individualized interventions to ensure that staff knew the needs of the resident when providing care and monitoring in the care environment, did not reflect that the resident was found smoking in his/her room, and did not reflect the interventions identified in the behavioral plan. Resident #39 was assessed a high risk and determined to be a dependent smoker under facility policy. Care plans were not revised and interventions were not implemented to protect this resident from further burns, and or to protect other residents from fire. On 06-20-17 at 1:20 PM, surveyor interview of the Director of Nursing provided no additional information. 2. On 06-20-17 surveyor review of the clinical record for resident # 62 revealed that, on 03-19-17, a safe smoking evaluation was completed by the facility staff, after the resident was observed on 03-18-17 with a burn hole on the outer layer of the his/her gown, while outside in the facility's smoking area. Further review of the evaluation revealed the resident was a dependent smoker and that a smoking apron as well as supervision by facility staff would be provided when the resident smoked. In addition, since the resident was now deemed as a dependent smoker, all of the resident's smoking materials (cigarettes and lighter materials) were to be kept at the nurse's station and not kept by the resident. On 05-04-17 at 8:24 PM, a concurrent review revealed that LPN #7 was alerted by other residents at 7:30 PM that resident #62 was in the smoking area with his/her clothes on fire, and that he/she was refusing to remove them. LPN # 7 further documented that the resident's observed mental state was confused and listed witnesses to the incident as other residents. However, there was no documented evidence that facility staff were present at the time of the incident even though the resident, a dependent smoker since 03-18-17, required supervision when he/she smoked. Further record review revealed a comprehensive plan of care, initiated on 11-17-16, for Potential for Complications related to actual use of cigarettes, with interventions including return smoking materials to the nurses station, accompany and remain with this dependent smoker during smoking breaks. However, there was no evidence of facility staff presence during the incidents on 03-18-17 and 05-04-17 . In addition, there was no evidence of a reassessment of the safe smoking evaluation completed by staff, and or evaluation of the care plan interventions after the second incident of resident #62's gown catching fire. On 06-20-17 at 2:30PM, surveyor interview with LPN #8 revealed that resident #62's smoking materials, including cigarettes and lighter, were not in the medication cart, but were kept by the business office staff member who provided them when the resident wanted to smoke. Other residents do have access to the designated smoking area by knowing the key code to the door accessing the outside smoking area and were able to go out on their own. Further observation of the locked west wing medication carts revealed no evidence of smoking materials for any residents. On 06-19-17 at 2PM, surveyor interview with resident #101 revealed that, on 5/14/17, he/she had observed resident #62 outside on the smoking porch when the resident's gown caught fire. Further interview revealed that other residents were also outside smoking, that there was no facility staff present at the time, and that other residents needed to alert staff to the fire. Resident #62 refused to remove their gown and staff had to rip the gown off of the resident. On 06-20-17, review of 01-05-17 documentation by the facility's psychologist consultant revealed that resident #62 had behavioral symptoms that included, active delusional ideation, paranoia and noncompliance. In addition, the resident had poor problem solving, poor ability to follow commands, and mixed delusional thought content. Further record review revealed a comprehensive plan of care, initiated on 11-17-16, for Potential for Complications related to actual use of cigarettes with interventions that included smoking materials kept at the nurses station and staff accompanying and remaining with dependent smokers during smoking breaks. However, there was no evidence of facility staff presence during the incidents on 03-18-17 and 05-04-17 when resident #62 was found in the smoking area with a burning gown. In addition, there was no evidence of a reassessment of the safe smoking evaluation completed by staff and evaluation of the care plan interventions after the 2nd incident when the resident's gown caught fire after the 05-04-17 incident. (Refer to F280 for additional information) On 06-20-17 at 12:45PM, surveyor interview with the Director of Nursing and the facility administrator revealed no additional information. 3. On 06-19-17 at 3:30 PM, surveyor interview with resident #208 revealed that he/she was recently admitted to the facility for rehabilitation after a hospitalization . The resident had shortness of breath and was dependent on oxygen, but continued to smoke. Since admission to the facility, the resident smoked in the outside designated smoking area of the facility accessible via a coded exit door. The resident's portable oxygen machine remained with the resident when smoking, but the resident removed the nasal cannula while smoking. In addition, the resident kept all smoking materials at the bedside, which included cigarettes and lighter, until he/she chose to smoke. Record review revealed social services documentation on 06-05-17 that resident #208 had a BIMS score of 12 out of a possible 15, while on 06-19-17, the resident's total BIMS score was 14 out of 15. BIMS (Brief Interview for Mental Status) is a test given by medical professionals that helps determine a resident's cognitive understanding. A BIMS score of 13-15 indicates cognitively intact, while a score of 8-12 indicates moderately impaired. On 06-19-17 at 3:15PM, surveyor observation of the facility's outside designated smoking area revealed resident #208 smoking with the portable oxygen machine located at the resident's side in the wheelchair, while the nasal cannula was not connected to the resident while smoking. However, on 06-20-17, surveyor review of the facility's current list of smokers in the facility revealed no evidence of resident #208, who was admitted to the facility on [DATE] . On 06-20-17, review of the facility's policy and procedure for smoking revealed that a safe smoking assessment is completed for all smokers at the time of admission, quarterly, annually and following any significant change or when unsafe practices are noted. However, record review revealed no evidence of a safe smoking evaluation and/or assessment of resident #208 who was a smoker and was oxygen dependent, until surveyor intervention on 06-20-17. In addition, there was no evidence of a care plan related to smoking safety regarding the oxygen, and smoking for the resident as well as other residents. (Refer to F272 for additional information) On 06-23-17 surveyor review of the facility's policy and procedure for oxygen administration revealed a No smoking oxygen in use sign on the resident's doorway. There were no other instructions regarding the use of oxygen and smoking in the facility's policy. On 06-20-17 at 12:45PM, surveyor interview with the facility administrator and the Director of Nursing revealed no additional information. 4. Further record reviews after 06-20-17 revealed that resident #65 was identified as a high risk smoker after a number of behavioral incidents of resident smoking in his/her room. On 06-21-17, record review revealed nursing notes documented on 05-28-17 at 3:46PM, 05-29-17 at 9:15PM, 06-02-17 at 6:33PM, and 06-06-17 at 8:47PM, that resident #65 was observed by staff at each incident, smoking in the their room. The resident was educated by staff regarding the prohobition of having a lighted cigarette in their room, and the possible hazard to the resident, roommate, as well as other facility residents. However, the resident continued to repeat the behavior. Additionally, administrative staff issued a Notice of Violation of Guidelines or Resident Behavior after each incident of unsafe smoking which identified that the conduct violated the facility's Guidelines for Resident Behavior and additional administrative action may include but are not necessarily limited to, discharge from the facility under circumstances meeting federal and state conditions for involuntary discharge. However, the administrative action taken by the facility after each incident with resident #65 was only behavioral care plan and counseling by social work staff. Further record review revealed a safe smoking evaluation, completed by staff on 05-25-17, which assessed resident #65 as a independent smoker. However, there was no evidence that a reassessment of the safe smoking evaluation was completed by staff after each of the above behavior incidents, when the resident was found smoking in the room. On 06-21-17 at 4PM, and 06-28-17 at 6PM, surveyor interview with the facility administrator and the Director of Nursing revealed no additional information.

Based on medical record review, facility policy and procedure, and staff interviews, it was determined that the facility failed to maintain a safe environment for resident #3, who was identified as an elopement risk, and for resident #1, who had a history of [REDACTED]. Additionally, when resident #1 successfully eloped, the facility failed to notify the law enforcement authorities in a timely manner. This finding was evident in 2 out of 4 residents identified as at risk for elopement. (#1 and #3) These deficient practices placed residents at risk for elopement and the potential for serious harm. The findings include: 1. An Immediate Jeopardy to residents' health and safety was determined by the State Office of Health Care Quality on [DATE] at 4:20 PM. The immediate jeopardy was abated on [DATE] at 7:30 PM following the facility's implementation of corrective actions to ensure the health and safety of all residents who were at risk for elopement. This finding was identified during the investigation of the facility reported incident #MD 465 for resident #1. On [DATE], surveyor review of the clinical record for resident #1 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed a [DATE] at 2:43 PM social service note stating that resident #1 was seen by the physician and psychologist and deemed incapable of making medical decisions for their own self. The resident expressed a desire to return home with their parents, who were on vacation. However, the resident's parents died in 1976 and 1978 and the house the resident wanted to return to was sold in 1980. In addition, on [DATE] at 2:51 PM, a physician's progress note revealed that resident #1 wasn't able to tell (his/her) medical problems and wants to live with parents. The physician stated the resident has poor memory and is not able to make health care decisions or financial decisions. Surveyor review of the [DATE] psychologist note revealed that resident #1 was referred to {the psychologist} because (resident) was anticipating signing (self) out of the facility, but there were competency concerns. The resident had bagged up (his/her) clothing and had it sitting on the bed. The resident agreed to stay in the facility after being urged by the psychologist to wait until (the resident's) parents returned. The psychologist stated that resident #1 allowed for a GNA (geriatric nursing assistant) to unpack (resident's) clothing. Under the heading of plan the psychologist's note revealed resident lacks capacity for financial and medical decision making based on impaired memory and delusional thought process. Further review of the clinical record revealed an incapacity form, dated [DATE], that stated resident #1 was unable to understand and sign admission documents and other information, unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment, unable to make rational evaluation of the burdens, risks, and benefits of treatment, unable to effectively communicate a decision, and incapable of making decisions regarding CPR (cardiopulmonary resuscitation). The [DIAGNOSES REDACTED]. However, despite resident #1's delusions regarding parents and home, expressing intentions to leave the facility, and the change in behavior requiring a capacity evaluation, there was no evidence of an updated elopement assessment, a nursing assessment of the change in behavior, or the development of a care plan addressing the risk of elopement or delusional behaviors. Surveyor review of the [DATE] facility reported incident revealed that resident #1 was seen sitting in front of the facility by several staff members as this was his/her norm around 7:,[DATE]:45 AM. Then, at 8 AM, facility staff could not locate the resident. Staff notified police on [DATE] at 11:12 AM, which was three hours after the resident was noted to be missing. Surveyor review of the nurses note, on [DATE] at 2:46 PM, revealed that resident #1 was last seen around 8 AM by a staff member on their way to work. The therapist came out to get (resident #1) for therapy (resident) was no longer at the front area. An alert was put out and staff searched the immediate area. The physician was notified at 8:15 AM, and the responsible party was notified at 8:30 AM. In addition, a note written on [DATE] at 4:23 PM, revealed that resident #1 had returned to the facility at 3:45pm. The resident stated he/she went to his/her parents house and stated in a few weeks (they) will try again. Further review of the clinical record revealed that an elopement assessment was updated on [DATE], which indicated that resident #1 was an elopement risk. Interventions were initiated that included; a wander guard bracelet was placed on the resident, a picture was placed in the elopement book at the front desk, and a care plan was developed to address the elopement risk. A Wanderguard is an alarm system used in wandering or elopement management. The system usually involve some type of antenna system connected to a controller and a door contact switch. Residents who are at risk wear a wrist or ankle transmitter, and if the transmitter comes in contact close to the door that is protected by this type of system, the antenna singles out the transmitter of the resident. Review of the care plan, developed on [DATE], revealed that resident #1 verbalized to the therapist wanting to leave but did not say (he/she) was leaving. Therapist was also educated. Further review of the facility's investigation of the elopement revealed a statement written by the therapist that stated resident #1 was seen at the curb in front of the shell station. In addition, it was 8:00 AM. Resident stated that (he/she) was heading to Takoma Park (a near by town). Surveyor review of the statement written by the receptionist on duty [DATE] revealed that resident #1 went outside around 7:45 AM. Another staff member informed the receptionist that the resident was outside, but the receptionist stated it was okay, normally {the resident} just goes outside and sit. The receptionist also stated that, at 8 AM, another staff member informed him/her the resident was at the bus stop. On [DATE] at 8 AM, surveyor interview with the DON (Director of Nursing) revealed that per interview with resident #1, the resident had taken a cab to a house in Takoma Park, where there was an interaction with the people that resided in the home. The police were notified by the homeowners at which time the resident was asked to leave and the resident returned to the facility in a cab. The DON stated that staff did not call the police right away, because the resident typically sits outside and doesn't go anywhere, so they thought they could find resident #1 in the area. On [DATE] at 9:15 AM, surveyor interview with staff #6 revealed that this staff member had seen the resident outside on the corner at the Shell station and the resident stated he/she was going to Takoma Park. The staff member then went into the facility and let the front desk receptionist know the resident was outside and the receptionist said that's ok. When the staff member went downstairs, looked at the schedule and noted the resident was to be seen that day, he/she called back to the receptionist who called the nursing unit, and was told the resident was not signed out. 2. Based on surveyor review of the clinical record, review of the facility's policy and procedure and interview with resident and facility staff, it was determined that the facility failed to implement interventions to prevent elopement for resident #3, who was identified as an elopement risk at the time of admission. This finding was identified during the investigation of facility reported incident MD 123. Refer to F225 for additional information. On [DATE], review of the facility's policy and procedure for Elopement/Prevention/Intervention revealed that an elopement risk assessment is completed for all new admissions, readmissions, quarterly, annually, and with any significant change and implement interventions to prevent elopements. Staff are to complete the elopement risk assessment, and if the resident scores as an elopement risk, the following is to be completed: place a picture of the resident at the facility's front desk, apply Wanderguard to wrist or an area directly touching skin and care plan resident for risk of elopement. An Elopement Risk Score of 10 or > means risk for elopement. Further record review revealed that, upon admission to the facility, staff documented on [DATE] that an elopement assessment was completed for resident #3 with a total risk score of 12, indicating that resident #3 was at risk for elopement. However, there was no evidence that the staff documented any interventions put into place, or developed a plan of care for resident #3, with a risk for elopement with a total risk score of 12 as of [DATE]. There was no evidence that the use of a Wanderguard was put in place, that a picture of the resident was placed at front desk in the elopement binder, or that a care plan was initiated. On [DATE], record review revealed that, on [DATE], staff documented that resident #3 attempted to leave the facility and was able to be re-directed back to the facility after several facility staff members spoke with the resident. Further review revealed that, on [DATE], staff documented an elopement risk assessment completed with a total risk score of 24 and placement of a Wanderguard, resident picture at front desk and care plan initiated for elopement potential. On [DATE] at 2 PM, surveyor interview with the Director of Nursing revealed no additional information.

Based on surveyor observation and review of the clinical record, interview of facility staff, and review of facility documents, it was determined that the facility failed to ensure the safety and security of the Terrace Unit and provide appropriate monitoring to prevent the elopement of resident #1. This finding was identified in the investigation of Complaint MD 236 and is considered valid. As a result, the following safety measures were not met which determined immediate jeopardy. The findings include: On 04-08-11, according to the complaint information and interview with the Director of Nursing (DON) at approximately 2:00 PM, resident #1 was confused from dementia and wandered off the Terrace Unit and out of the facility on 04-05-11. The DON stated that a facility camera showed the resident left the building at 6:55 PM; however staff were not aware the resident was missing until approximately 11:30 PM when they were notified the resident was at the hospital by emergency room staff. A member of the community had found the resident wandering on the road and drove him to the hospital for fear of being injured. It was reported that the resident did not have an identification band on at the time. Following the resident's discharge from the hospital emergency room , the resident did not return to the facility because " the family did not feel that the nursing home was a safe environment to return the resident to", according to the complaint information. Further interview with the DON on 04-08-11, review of facility documents regarding the elopement incident, and review of resident #1's clinical record revealed that the resident's plan of care included toileting every 2 hours and a pain assessment. However,review of the April 2011 Treatment Administration Record revealed nursing staff documented the resident was toileted at 8:00 PM and 10:00 PM and the April 2011 Medication Record revealed that nursing staff documented a pain assessment was done for the resident at 9:00 PM ( times when the resident was not in the facility). Based on interview with the DON and review of documented statements from the 3-11 shift employees responsible for the resident's care, nursing staff did not monitor the resident and documented a pain assessment and ADL care. On 04-08-11 at approximately 2:30 PM, surveyor observation during the initial tour of the Terrace Unit with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) revealed that the north door to enter/exit the Terrace Unit to the Adult Day Care Center and Rehabilitation units did not close and lock properly to secure the safety of the residents residing on the Terrace Unit. Observation of the doorway revealed that a security coded keypad must be operated by facility staff from either the inside or outside of the Terrace Unit to exit or enter through the doorway. However, interview and observation with the NHA and DON revealed that the door can appear closed, but be unlocked if not manually pulled on, and thereby the security coded keypad would not need to be operated to exit or enter the door. Further observation revealed that exterior doors directly outside the Terrace Unit, used for the building entrance to the Adult Day Care Center, were not double locked properly to maintain the safety and security of the building. Interview with the NHA and DON revealed that the exterior doors are locked by facility staff after the Adult Day Care Center closes at 5:00 PM. However, it was determined by the facility, after the elopement of resident #1, that staff were unaware that a locking mechanism on the top of the door frame needed to be manually triggered for the building's exterior doors to be properly locked. Interview with the NHA and DON revealed the facility implemented corrective safety measures to include a 15 minute door and resident watch at the north door on the Terrace Unit and facility staff training of the proper locking of the Adult Day Care Center entrance doors. However, based on surveyor observation on 04-08-11 at 3:15 PM, the north door to enter/exit the Terrace Unit to the Adult Day Care Center and Rehabilitation units was unlocked when a 15 minute safety check was being performed by the unit nurse. In addition, based on surveyor observation on 04-08-11 at 3:10 PM with the DON, the south door to enter/exit the Terrace Unit from the elevator hallway was not securely locked. Observation revealed that the door appeared closed, but was unlocked without forcibly pushing on the closed door several times. Observation of this doorway revealed that a security coded keypad must be operated by facility staff from the inside of the Terrace Unit to exit through the doorway. This door had not been previously identified as an unsecured door on the Terrace Unit until surveyor observation. In addition, surveyor observation of the 16 residents residing on the locked Terrace Unit on 04-08-11 at approximately 4:30 PM revealed that 10 of the 16 residents did not have an identification band on. Interview with the NHA and DON revealed the DON stated she had asked a staff member to make identification bands for those residents without them. Also, pictures were to be taken of residents identified to be at high risk for elopement.