Every finding on record at Hartley Nursing and Rehab

Based on observation, interview and record review, it was determined that the facility failed to develop and implement comprehensive care plans for the use of 1) oxygen (O2) therapy and 2) cardiac medications. This was evident for 4 (Residents #45, #62, #53 and #2) of 23 residents reviewed for care planning during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each Resident. It is used to plan, assess, and evaluate the effectiveness of the Resident's care. The care plan consists of focus, goal and interventions. 1a. On 1/14/2026 at 10:30 AM, during the initial tour of the facility, Resident #45's O2 concentrator was found turned off with tubing on the floor, under the bed. On 1/14/2026 at 10:39 AM, Unit Manager (UM #2) was informed of the findings and confirmed that Resident #45 was currently on O2 therapy. On 10/16/2025 at 10:45 AM, during an interview with the Director of Nursing (DON), she stated that resident's care plan was initiated by the UM and updated by the DON as needed.On 1/20/2026 at 8:39 PM, a review of Resident #45's Physician orders indicated an order 02 at 2L (liters) /minute via nasal cannula (NC) continuous related to (r/t) low saturations (sats) every shift The following progress notes confirmed that Resident #45 was on O2 therapy:1/12/2026 05:46 Orders- Administration Note Text: 02 at 2L/min via NC continuous r/t low satsevery shift1/15/2026 00:19 Orders- Administration Note Text: 02 at 2L/min via NC continuous r/t low satsevery shift1/16/2026 02:25 Orders- Administration Note Text: 02 at 2L/min via NC continuous r/t low satsevery shift1/19/2026 23:28 Orders- Administration Note Text: 02 at 2L/min via NC continuous r/t low satsevery shiftThe medical record did not indicate any evidence that an O2 therapy care plan was in place.On 1/21/2026 at 10:05 AM, the surveyor received a copy of Resident #45's O2 care plan which was initiated on 1/21/26 after surveyor intervention.1b. On 1/14/2026 at 9:58, Resident #62 was observed using O2 via NC connected to a cylinder tank. UM #2 stated that probably the facility ran out of O2 concentrators. On 10/16/2025 at 10:45 AM, the DON was informed that Resident #62 had no O2 care plan.On 1/20/2026 at 9:45 PM, a review of Resident #62's order confirmed the use of O2 via NC at 3L/min for shortness of breath (SOB)/low pox (oxygen saturation) every shift. However, a care plan for O2 use was created on 1/16/26 after surveyor intervention.1c. On 1/14/2026 at 9:53 AM, Resident #53 was observed in bed receiving O2 therapy via NC.On 1/15/2026 at 12:37 PM, a review of Resident #62's physician orders did not indicate any evidence that an O2 order was placed, nor a care plan was initiated and implemented.A change in condition noted dated 1/12/2026 at 11:28 PM confirmed that Resident #53 was on O2 at 3L/m via NC. On 1/21/2026 at 10:15 AM, a review of the facility's oxygen administration policy which was reviewed and revised on 4/18/25 required the following, 1. Oxygen is administered under orders of a physician, except in the case of emergency. 4. The Resident's Care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders.On 1/21/2026 at 11:25 AM, the DON and Assistant Director of Nursing (ADON) were informed of the concerns and acknowledged the findings. 2. On 1/20/2026 at 8:00 PM, a review of Resident #2's medical record indicated an admission date of 11/18/25 and a discharge to the hospital on [DATE]. A review of the change in condition report dated 12/29/25 indicated the following: a. Abnormal vital signs- elevated pulse of 123, respiration of 36 and low blood pressure of 60/39b. Change in mental status- difficult to arouse, general weaknessThese findings were confirmed by a Physician's discharged note dated 12/30/25 at 7:27 PM. Further review of Resident #2's order summary indicated that he/she was prescribed the following medications: - Amiodarone (hydrochloride) HCl Oral Tablet 200 MG for chronic atrial fibrillation (irregular heartbeat which may lead to fatigue, shortness of breath and increases stroke risk.- Amlodipine Besylate Oral Tablet 10 MG (Amlodipine -Besylate) for hypertension (a blood pressure reading of 130/80 or higher)- Apixaban Oral Tablet 5 MG for chronic atrial fibrillation- Aspirin Oral Tablet Chewable 81 MG for cerebral infarction (is a type of stroke where a blockage such as blood clot, cuts off blood flow to part of the brain)- Atorvastatin Calcium Tablet 80 MG hyperlipidemia (high levels of bad cholesterol in the blood- Furosemide Oral Tablet 40 MG for heart failure (a condition when both left and right side of the heart are too weak to function)- Metoprolol Succinate extended release (ER) 50 mg Tablet for hypertension- Eliquis 5 MG Tablet for cerebral infarction- Sacubitril-Valsartan Oral Tablet 49-51 MG for heart failureHowever, the medical record did not show the care plan addressing these medications were initiated. On 1/21/2026 at 11:43 AM, the DON confirmed that facility failed to initiate the required care plan. On 1/23/2026 at 8:45 AM, the Nursing Home Administrator (NHA) was notified of these concerns.

Based on observation, interview, and record review, it was determined that the facility failed to provide necessary respiratory care services by failing to label oxygen administration equipment. This was evident for 4 (Resident #57, #53, #62 and #45) of 4 residents reviewed for respiratory care during the recertification survey. The findings include: Oxygen (O2) therapy is a treatment that provides a person with extra O2 to breathe in. It is also called supplemental O2. A nasal cannula is a thin, flexible tube that delivers O2 through the nose. A humidifier in O2 therapy is a device that adds moisture to dry, concentrated O2 to prevent drying and irritation of a patient's nasal passages, throat, and lungs. These humidifiers typically consist of a bottle filled with water that attaches to an O2 concentrator. On 1/14/2026 at 9:47 AM, during the initial tour of the facility, Resident #57 was observed in bed receiving O2 therapy via nasal cannula (NC), both the tubing and the humidifier bottle were unlabeled. On 1/14/2026 at 9:53 AM, Resident #53 was also observed using unlabeled tubing and an unlabeled humidifier. On 1/14/2026 at 9:58, Resident #62 was using unlabeled tubing that was connected to a cylinder tank.On 1/14/2026 at 10:30 AM, Resident #45's O2 concentrator was found turned off. Neither the tubing nor the humidifier bottle were labeled with the date of use nor the scheduled replacement date. On 1/14/2026 at 10:39 AM, Unit Manager (UM #2) was informed of the findings and verified these observations. He/she stated that O2 tubing were changed every Tuesday night, and the humidifier as needed. She added that it was expected that O2 tubing and humidifier bottles were labeled accordingly. On 10/16/2025 at 10:45 AM, the Director of Nursing (DON) was informed of these concerns and acknowledged the findings. On 1/23/2026 at 8:45 AM, the Nursing Home Administrator (NHA) was notified of these concerns.

Based on a review of staffing sheets and interview, it was determined that the facility failed to ensure a registered nurse (RN) was on duty of at least 8 consecutive hours, 7 days a week. This was evident for 2 of 23 days reviewed during the recertification survey and has the potential to affect all residents. The findings include: On 1/20/2026 at 10:14 AM, a review of the staffing sheets revealed that no RN worked during the 7-3 and 3- 11 shifts on Sunday, January 4, 2026, or the 3-11 shift on Saturday, January 10, 2026. On 1/21/2026 at 12:22 PM, in an interview with the Director of Nursing (DON), she confirmed that although she was the on-call RN on January 4, she was unable to fulfill her duties due to personal reasons. On 1/21/2026 at 12:34 PM, the Assistant Director of Nursing (ADON) confirmed she was the on- call RN on January 10 but did not report to the facility. Both the DON and the ADON have been notified of these concerns.

Based on observations and staff interviews, it was determined that the facility failed to store and prepare food in a manner that maintained professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include:During the initial tour of the kitchen conducted on 01/14/2026 at 9:40 AM, the Surveyor and Food Service Director observed multiple food items stored in the dry storage area that were opened and undated or had illegible labeling. The food items were identified as follows: 2 packs of ziti noodles, opened and undated; 2 packs of elbow noodles, opened and undated; 1 pack of egg noodles, opened with illegible labeling; 2 packs of egg noodles, opened and undated; 1 pack of spaghetti noodles, opened and undated; 1 box of egg noodles, opened with no expiration or open date; 1 bag of toasted oats cereal, opened and undated; and 1 bag of crisp rice cereal, opened and undated.During a continued tour of the kitchen, the Surveyor and Food Service Director observed food items stored in the walk-in refrigerator that were opened and undated. The food items were identified as 1 box of ground beef, opened and undated; 1 box of natural smoked bacon, open to air and undated; 1 bag of red potatoes, opened and undated; and 3 packs of French toast, opened and undated.In an interview conducted on 01/14/2026 at 9:55 AM, the Food Service Director stated that the facility's expectation was for food items to be securely closed once opened and labeled with an open date and expiration date to ensure safe food storage.During a continued tour of the kitchen, the Surveyor and Food Service Director observed food items stored in the walk-in freezer that were opened, exposed to air, and undated. The food items were identified as 1 box of corn, open to air and undated; 1 box of cultivated blueberries, open to air and undated; 1 box of pizza dough, open to air and undated; 1 bag of sugar cookie dough, opened and undated; 1 box of philly beef sandwich slices, opened and undated; 1 box of breakfast turkey sausage patties, opened and undated; 1 box of bulk beef hamburger patties, opened and undated; and 1 pack of hot dogs, opened and undated.During continued observations of the dishwashing area on 01/14/2026, the Surveyor and Food Service Director observed the facility's high-temperature dishwasher in operation. The wash cycle temperature reached approximately 140 degrees Fahrenheit (F) as indicated on the dishwasher manifold gauge, which was below the required wash temperature of 150 degrees F. The rinse cycle temperature reached approximately 186 degrees F; however, the temperature gauge remained fixed and did not reset to zero during or after the cycle.In an interview conducted on 01/14/2026 at 10:43 AM, the Food Service Director stated that the dishwasher was expected to reach required wash (150 degrees F) and rinse (180 degrees F) temperatures.During a follow-up kitchen tour conducted on 01/21/2026 at 11:08 AM, the Surveyor and Food Service Director again observed the facility's high-temperature dishwasher in operation. The wash cycle temperature reached approximately 144 degrees F as indicated on the dishwasher manifold gauge, which was below the required wash temperature of 150 degrees F. The rinse cycle temperature reached approximately 190 degrees F; however, the temperature gauge again remained fixed and did not reset to zero during or after the cycle.On 01/23/2026, the Administrator was made aware of the above findings.

Based on record review and interviews, it was determined that the facility failed to notify the Physician and Resident Representative (RP) of the residents' change in condition. This was evident for 2 (Resident #5 and Resident #57) of 4 residents reviewed for hospitalizations during the recertification survey. The findings include: 1. On 1/22/26, review of Resident #5's clinical record revealed that the resident was transferred to the hospital on 1/6/26 following a change in condition and returned to the facility on 1/14/26. There was no documentation in the clinical record to verify that the physician was notified of Resident #5's change in condition on 1/6/26. Further review of Resident #5's clinical record revealed a late entry nursing progress note dated 1/7/26 that was entered into PointClickCare (PCC), the facility's electronic medical record system, on 1/15/26. The progress note revealed that Resident #5 had a change in mental status and abdominal pain and was sent to the emergency room for evaluation and treatment; however, the note did not include documentation to show that the physician was notified of Resident #5's change in condition. On 1/22/26 at 10:30 AM, an interview with the Assistant Director of Nursing (ADON) revealed that when a resident has a change in condition, nursing staff is expected to notify the physician. The ADON stated that physician notification is documented by nursing staff in a Change In Condition (CIC) note in PCC. At 10:34 AM, the surveyor requested documentation to verify physician notification for Resident #5's change in condition, which resulted in hospital transfer on 1/6/26. In a follow-up interview on 1/22/26 at 11:05 AM, the ADON confirmed that no CIC note was completed for Resident #5 and stated that only a late entry progress note dated 1/7/26 was in PCC. At the time of the exit conference, no documentation was provided to verify that the physician was notified of Resident #5's change in condition, which resulted in a hospital transfer on 1/6/26. 2. Pulse oximetry is a noninvasive, painless method to measure the oxygen saturation level in the blood (SpO2) and pulse rate using a small device (pulse oximeter) usually placed on the finger. A normal healthy reading is generally 95-100 %. Readings below 92 % may indicate low oxygen, and levels at 88% or lower require immediate medical attention. On 1/22/26 at 9:13 AM, a review of Resident #57's change in condition report dated 12/7/25 at 5:29 PM indicated the following: Situation: Shortness of breath Pulse Oximetry: SpO2 88% Method: O2 via nasal cannula Primary Care Provider Feedback: A. Recommendations: send to emergency room for evaluation and treatment. Despite these clinical developments, the report contained no evidence that the RP was notified of the change in condition. On 1/22/26 at 12:09 PM, the Director of Nursing (DON) provided a copy of the report and confirmed that the RP had not been notified and acknowledged this concern.

Based on observations and interviews, it was determined that the facility failed to provide clean, comfortable and homelike environment for residents. This was evident for 2 (Resident #1 and Resident #48) during an initial tour of the facility. 1.On 1/14/26 at 10:25 AM during rounds the surveyor observed Resident #1 lying in bed with a wheelchair at the bedside. The resident stated that his/her bathroom door was locked for weeks and he/she could only use the bathroom when a staff member was present. The surveyor tried to open the bathroom door, but it was locked. Also, on the floor next to the wall facing the resident were several items. The items included a pair of wheelchair foot-rests, and a cardboard box containing personal items such as shoes and clothing.The surveyor informed Staff LPN #7 of the concerns and Staff LPN #7 accompanied the surveyor to Resident #1's room and confirmed the findings. Staff LPN #7 stated that the bathroom door was locked to protect the resident from falls. She also stated that the items on the floor should not be there and that she would have them removed. The surveyor asked to speak to the Director of Nursing (DON). Later at 11:50 AM the DON arrived in the resident's room. The DON tried to open the resident's bathroom door and confirmed that it was locked. The DON stated that the door was locked because Resident #1 was a fall risk and he/she would try to use the bathroom without calling for help. Further, Resident #1 was usually incontinent and was dependent on staff for toileting.On 01/15/26 at 7:45 AM a review of the resident's Care Plan for Falls, failed to reveal the locked bathroom was an intervention to keep Resident #1 safe. On 1/16/26 at 8:39 AM in an interview the DON was notified of the surveyor's concerns regarding the facility's failure to provide a comfortable homelike environment as evidenced by personal items on the floor and the resident not having access to his/her bathroom. The DON stated that she would address the findings. 2. On 01/14/26 at 10:54 AM the surveyor observed Resident #48 sitting at the side of his/her bed. On the floor under the window there were a box of crackers, a case of 8oz bottled drinking water, 2 bottles of shampoo and personal items in 3 gift bags. In an interview Staff LPN #7 who was with the surveyor confirmed the findings and stated that the items should not be on the floor and they would be removed.On 1/14/26 at 11:58 AM the DON accompanied the surveyor to Resident #48's room and confirmed the items on the floor. During an interview, the DON stated that she would address the concerns as food items were not allowed on the floor and the staff was expected to ensure that food was stored in containers with lids. She also stated that the other items would be removed from the floor.On 01/23/2026 at 8:57 AM during follow-up rounds the surveyor observed the case of bottled water, shampoo and other personal items still on the floor of Resident #48's room. The only item which was removed was the box of crackers. At 9:53 AM the surveyor again brought the concerns to DON's attention. I told the GNA (Geriatric Nursing Assistant) to remove them, I will remove them right now. The surveyor observed the DON removing the items from the floor.

Based on record review and interviews, it was determined the facility failed to review and revise the interdisciplinary care plans as changes in residents' treatment occurred. This was evident for 2 (Resident #3 and Resident #7) of 23 residents reviewed for care planning. The findings include:1. On 01/21/26 at 12:27 PM a review of Resident's #3 medical record revealed that on 12/23/25 the resident acquired an Arterial Ulcer to the Right Heel. The current treatment order for the ulcer is as follows: Cleanse Right Heel Arterial Ulcer with wound cleanser/normal saline. Apply calcium alginate, Medi honey to base of wound and secure with ABD and rolled gauze daily every evening shift - Start Date: 01/15/26Further review of the resident's medical record revealed that on 11/20/25 upon admission, a care plan was initiated which stated that the Resident #3 has potential for pressure ulcer development.The medical record failed to reveal that Resident #3's care plan was reviewed and revised to include the presence of an actual Arterial Ulcer. Further, there were no interventions in place to address the condition. On 01/22/26 at 10:25 AM during an interview, Unit Manager LPN #2 stated that residents' care plans were reviewed and revised in keeping with their condition. The Unit Manager LPN #2 reviewed the medical records and acknowledged that the care plan was not revised to include Resident #3's Arterial Ulcer. On 01/22/26 at 10:33 AM in an interview the Director of Nursing (DON) was informed of the concerns and acknowledged the findings. 2. A review of Resident #7's medical record revealed that the resident was admitted to the facility in April 2023 with diagnoses which included Atrial Fibrillation and Hypertension.Further review indicated that the resident was receiving anticoagulant, Eliquis 5mg by mouth twice a day for Atrial Fibrillation. Order Start Date: 11/12/25.The medical record failed to reveal that a Care Plan with interventions for anticoagulant therapy was implemented for Resident #7.On 01/22/26 at 10:10 AM during an interview Unit Manager LPN #2 stated that it was the practice for residents on anticoagulant therapy to have Care Plans with interventions for the condition. Unit Manager LPN #2 reviewed the clinical record with the surveyor and confirmed that a Care Plan was not initiated. On 01/22/26 at 10:30 AM in an interview the DON was informed of the findings, and she also reviewed the clinical record and confirmed the findings. The DON stated that a Care Plan should have been in place but it was missed.On 01/22/2026 at 10:57 AM the surveyor received an updated Care Plan from Unit Manager LPN #2 with interventions for Anticoagulant therapy for Resident #7.

Based on observation, record review and interview, it was determined that the facility failed to ensure that resident received treatment for a rash present since admission. This was evident for 1 (Resident #9) of 23 residents reviewed during the recertification survey. The findings include: Nystatin powder is a prescription medicine designed to treat skin infections caused by fungus or yeast. On 1/15/2026 at 8:59 AM, Resident #9 was observed with redness on the chest and confirmed the condition existed since admission. On 1/22/2026 at 6:18 PM, a review of Resident #9's medical record indicated an admission of 12/3/25 and a BIMS (Brief Interview for Mental Status) score of 15 which indicated intact cognitive function. A review of the skin treatment order written on 12/3/25 indicated: Nystatin External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to abdominal folds topically four times a day for yeast rash. However, no treatment was ordered for the chest/breast area.A review of the progress notes revealed the following:12/4/2025 00:45 Skilled Evaluation #006: New skin Issue. Location: Left breast, Issue type: Rash. Wound was present on admission.#007: New skin Issue. Location: Right breast, Issue type: Rash. Wound was present on admission 1/22/2026 18:09 Skilled Evaluation #004: Skin issue has not been evaluated. Location: Left breast. Issue type: Rash. Wound was present on admission.#005: Skin issue has not been evaluated. Location: Right breast. Issue type: Rash. Wound was present on admission on [DATE] at 8:39 AM, during an interview with the Assistant Director of Nursing/ Infection Preventionist (ADON/IP) Nurse, she stated that she was unsure if the Physician had been notified and committed to finding out why the issue remained unaddressed. On 1/23/2026 at 9:49 AM, a review of the skin treatment order revealed that a new order was written after surveyor intervention. Nystop External Powder 100000 UNIT/GM (Nystatin (Topical)) Apply to bilateral breast topically every day and evening shift for rash for 15 Days. On 1/23/2026 at 10:07 AM, in an interview with Registered Nurse (RN #6), he/she confirmed that on admission, the admitting nurse documents the skin issues in the medical record and the wound book for the wound nurse to review. On 1/23/2026 at 10:20 AM, the ADON/IP Nurse confirmed that the initial admission order failed to address the correct sites and stated that a corrected order has since been implemented.

Based on interview and record review, it was determined that the facility failed to ensure that nursing staff received competency evaluations upon hire and annually thereafter. This was evident for 3 (Geriatric Nurse Assistant GNA #8, Registered Nurse RN #9 and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed for staff competency during the recertification survey.The findings include: Nursing competence is defined by the American Nurses Association as an expected level of performance that integrates knowledge, skills, abilities, and judgment. On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. On 1/21/2026 at 8:27 AM, a review of the nursing employee records revealed the following: 1. GNA #8 was hired 2/23/24, no competency evaluation was found.2. RN #9 was hired on 10/10/23, no competency evaluation was found.3. LPN #12 was hired on 1/29/24, no competency evaluation was found. On 1/21/2026 at 9:48 AM, in an interview with GNA #16, he/she confirmed that he/she had not received any competency training since his/her hire date. On 1/21/2026 at 11:19 AM, the DON and the ADON/IP Nurse/Staff Educator, explained that competency training involved evaluating the nursing staff members through return demonstrations of skills listed on a competency checklist. The DON was notified that only 2 competency checklists were found among the reviewed files, and several staff members had no checklist at all. The ADON/IP Nurse/ Staff educator stated, That's all that we have, and confirmed that all the relevant documents were stored in employee folders and were not located elsewhere in the facility. They were notified of the concerns and acknowledged these findings.

Based on medical record review and interviews, it was determined that the facility failed to ensure that a recommendation by the consulting pharmacist was followed and documented on the resident's record. This was evident for 1 (Resident #11) of 5 residents reviewed for pharmacy recommendations. The findings include:On 1/20/26 at 11:45 AM a review of Resident #11's medical record revealed that the resident was receiving the medication Polyethylene Glycol Powder 17 gram by mouth daily for Constipation. Start Date: 09/22/25.Further review of the medical record revealed a recommendation by the facility's consulting pharmacist dated 8/01/25 with the following information Polyethylene glycol powder. Please add to mix 4 to 8 ounces of water or non-carbonated beverage of choice. The recommendation was reviewed and signed by the resident's physician on 8/11/25 with a note AGREE: Please write orders.A review of Resident #11's Medication Administration Record (MAR) revealed that from 09/22/25 to 01/20/25, the resident received the medication daily. The MAR did not contain documentation of the pharmacist's recommendation.In an interview on 01/20/26 at 1:19 PM, Unit Manager LPN Staff #3 stated that Resident #11 was hospitalized in September 2025 and upon return, the medication instructions were not updated on the MAR. Unit Manager LPN Staff #3 stated that she would update the record.In an interview on 01/20/26 at 1:44 PM the Director of Nursing was informed of the surveyor's concerns and acknowledged the findings.After the surveyor's intervention, Resident #11's medical record was updated on 01/21/26 to include the pharmacist's recommendation for Polyethylene Glycol Powder.

Based on observation, interview and record review, it was determined that the facility failed to use appropriate infection control practices such as 1) improper use and care of oxygen administration equipment, 2) improper storage of clean linens, and 3) inadequate infection surveillance. This was evident for 1) 1 (Resident #45) of 1 resident, 2) 1 of 1 laundry observation, and 3) 9 of 9 months of infection surveillance reviewed during the recertification survey.The findings include: 1) Oxygen (O2) therapy is a treatment that provides a person with extra O2 to breathe in. It is also called supplemental O2. A nasal cannula is a thin, flexible tube that delivers O2 through the nose. On 1/14/2026 at 10:30 AM, during the initial rounds of the facility, Resident #45's O2 concentrator was found turned off with the nasal cannula resting on the floor under the bed. On 1/14/2026 at 10:39 AM, Unit Manager (UM #2) was informed of the finding and verified this observation. He/she confirmed that nasal cannulas not in use should be stored in a clean plastic bag. On 10/16/2025 at 10:45 AM, the Director of Nursing (DON) was notified of this concern and acknowledged the finding. 2) On 1/20/2026 at 7:10 PM, a review of the infection tracking logs from May 2025 to January 2026 revealed significant inconsistencies. Logs lacked critical data, including unit and room numbers, onset dates, specific organisms, symptoms, and whether infections were hospital or community acquired. Furthermore, logs for May and September lacked the signatures of the Infection Preventionist (IP) Nurse and the dates of report to the Quality Assurance and Assurance (QAA) Committee. (QAA is Quality Assessment and Assurance is a mandated committee that reviews the facility data, identifies quality deficiencies and develops corrective action plans.) On 1/21/2026 at 10:39 AM, the Assistant Director of Nursing/ Infection Preventionist Nurse (ADON/IP Nurse) confirmed that daily infection surveillance for January was not available as the log was still being created. On 1/23/2026 at 8:45 AM, the Nursing Home Administrator (NHA) was notified of these systemic tracking failures and acknowledged the findings. 3) On 1/16/2026 at 8:46 AM, the Maintenance Director/ Environmental Services and Laundry Manager described the required infection control procedure for handling soiled linens, noting that staff must wear an apron or gown, mask, gloves, and a face shield. However, on 1/16/2026 at 8:54 AM, during a tour in the laundry area, several personal items including a can of soda, a box of facial tissue and a bottle of lotion were found on top of a table used for clean, folded linens. A cellphone was also observed on top of the clean folding table. The Maintenance Director was notified and acknowledged these concerns. On 1/16/2026 at 9:07 AM, the Nursing Home Administrator was also informed of these findings. On 1/23/2026 at 10:20 AM, Maintenance Director confirmed that he has completed education for the relevant staff regarding these laundry and infection control issues.

Based on record review and interview, it was determined that the facility failed to collect all the information required for monitoring antibiotic stewardship. This was evident for 9 of 9 months of antibiotic logs reviewed during the recertification survey. This deficient practice has the potential to affect all residents in the facility.The findings include:Antibiotic stewardship requires a facility to develop and implement policies, procedures and/or protocols to ensure residents who need antibiotics are treated appropriately. This is to reduce the risk of residents having adverse reactions to antibiotics, receiving them unnecessarily and/or developing antibiotic-resistant organisms. A facility-wide process must be in place to monitor the use of antibiotics so the results/feedback can be reported to nursing staff and prescribing clinicians.On 1/20/2026 at 7:10 PM, a review of the antibiotic surveillance logs from May 2025 to January 2026 revealed significant inconsistencies. Logs lacked critical data, including onset dates, room numbers, antibiotic order, diagnosis, ordering practitioner, and documentation supporting necessity. Furthermore, log for September lacked the signature of the Infection Preventionist (IP) Nurse and the dates of report to the Quality Assurance and Assurance (QAA) Committee. (QAA is Quality Assessment and Assurance is a mandated committee that reviews the facility data, identifies quality deficiencies and develops corrective action plans.) On 1/21/2026 at 10:39 AM, the Assistant Director of Nursing/Infection preventionist Nurse (ADON/IP Nurse) confirmed that daily antibiotic surveillance for January was not available as the log was still being created. On 1/23/2026 at 8:45 AM, the Nursing Home Administrator (NHA) was notified of these systemic tracking failures and acknowledged the findings.

Based on record review and interview, it was determined that the facility failed to screen, offer and educate the residents or the Responsible Parties (RP) of risks and benefits of pneumococcal vaccines and flu vaccines. This was evident for 4 (Resident #62, #57, #45 and #9) of 5 residents randomly reviewed for immunizations. The findings include: According to Centers for Disease Control (CDC), flu vaccine is an annual injection (or nasal spray) recommended for everyone 6 months and older to protect against influenza, while pneumococcal vaccines prevent serious bacterial infections causing pneumonia, meningitis and sepsis. On 1/21/2026 at 1:08 PM, a medical record review revealed the following:- Resident #62: admitted [DATE], the record lacked evidence that the pneumococcal vaccine was offered upon admission or thereafter.- Resident #57: Originally admitted [DATE] with a recent readmission on [DATE]; the record lacked evidence that pneumococcal and flu vaccines were offered. While the Director of Nursing (DON) stated consents were with the family, there was no documentation of vaccine refusal in the medical record. - Resident #45: admitted [DATE], the record lacked evidence that the pneumococcal vaccine was offered upon admission or thereafter. - Resident #9: admitted [DATE], the record lacked evidence that flu and pneumococcal vaccines were offered until 1/21/26, when consents were signed following surveyor intervention. On 1/22/2026 at 9:15 AM, a review of the General Immunization/ Vaccination policy (reviewed on 6/11/25), indicated the following:1. It is the policy of this facility, in collaboration with the medical director, to have an immunization program against infectious disease in accordance with national standards of practice2. Immunizations will follow current CDC guidance and scheduling based on specific vaccinations3. Residents, staff and volunteer workers will be offered immunizations against infectious disease as per current federal, state and local guidance.4. Residents, staff and volunteer workers will be screened prior to receiving any immunizations to ensure eligibility for the specific vaccines.On 1/22/2026 10:30 AM, the ADON/Infection Preventionist Nurse(ADON/IP) confirmed that pneumonia, flu, and COVID-19 vaccines were not routinely checked upon admission. Later that day, at 2:10 PM, vaccine declinations for Resident #57 (signed on 1/22/26 after surveyor intervention) were provided. Unit Manager (UM#2) confirmed that while immunizations are part of the admission process, they have not been completed consistently. On 1/23/2026 at 8:45 AM, the Nursing Home Administrator (NHA was informed of the concerns.

Based on record review and interviews, it was determined that the facility failed to offer and provide required education regarding the benefits, risks, and potential side effects of COVID-19 vaccine to residents and staff. This was evident for 3 (Registered Nurse RN #10, Geriatric Nurse Assistants GNA #10 and #11) staff members and 4 (Resident #57, #45 and #9) of 5 residents randomly reviewed for immunizations. The findings include: According to Centers for Disease Control (CDC), COVID-19 vaccines are recommended for individuals aged 6 months and older to protect against severe illness, hospitalization, and death. These vaccines work by training the immune system to recognize and fight the virus, with protection decreasing over time, making updated doses necessary especially for high risk groups.A) 01/20/2026 at 10:15, the surveyor requested 5 random employee health records, however, the Assistant Director of Nursing/Infection Preventionist Nurse (ADON/IP) stated, we don't require immunization for staff, whatever is in the employee file, that's it. The Director of Nursing (DON) was present during the conversation. On 1/20/2026 at 12:30 PM, an initial review of employee health records revealed that RN #9 with a hire date of 10/10/23, GNA #10 with a hire date of 3/19/25, and GNA #11 with a hire date of 11/1/22 showed no immunization record on their employee files. On 1/21/2026 at 11:19 AM, the DON and ADON/IP Nurse were notified of the concerns and acknowledged the findings. The ADON/IP Nurse reiterated that all the documents should be in the employee files. On 1/23/2026 at 1:20 PM, the Nursing Home Administrator (NHA) provided the surveyor with the list of employees that have immunization records on file. The surveyor informed the NHA that the 5 staff members that were randomly reviewed were not on the list except for 1 staff that had been previously recorded. On 1/23/2026 at 1:47 PM, while the ADON/IP Nurse provided the immunization records of these employees (GNA #10, GNA#11 and RN #9), the files contained no evidence that the COVID-19 vaccine had been offered, or the related education had been provided. B ) On 1/21/2026 at 1:08 PM, medical record reviews revealed a lack of documentation regarding COVID-19 vaccine offers or education for the following:- Resident #57: No evidence of vaccine offer or education in the record. A declination was only signed on 1/22/2026 following surveyor intervention.- Resident #45: The record lacked evidence of both vaccine offer and education.- Resident #9: No evidence of vaccine offer or education was documented until 1/21/2026, when consents were signed following surveyor intervention. On 1/22/2026 at 9:15 AM, a review of the General Immunization/ Vaccination policy (reviewed on 6/11/25), indicated the following relevant sections:3. Residents, staff and volunteer workers will be offered immunizations against infectious disease as per current federal, state and local guidance.4. Residents, staff and volunteer workers will be screened prior to receiving any immunizations to ensure eligibility for the specific vaccines.8. Staff, volunteer workers, residents or resident representatives will be required to sign a consent form prior to administration of the vaccine(s). The completed, signed, and dated record will be filed in the individual's [NAME] record, or the staff or volunteer's medical file.10. The resident's medical record or staff/ volunteer's medical file will include documentation that the staff, volunteer, resident and/or the resident's representative was provided with education regarding the benefits and potential side effects of immunization(s), and that the resident received or did not receive the immunization(s) due to medical contraindication or refusal.On 1/22/2026 10:30 AM, the ADON/IP Nurse confirmed that pneumonia, flu, and COVID-19 vaccines were not routinely checked upon admission. Later that day, at 2:10 PM, vaccine declinations for Resident #57 (signed on 1/22/26 after surveyor intervention) were provided. Unit Manager (UM#2) confirmed that while immunizations are part of the admission process, they have not been completed consistently.

Based on record review and interview, it was determined that the facility failed to provide evidence that nursing staff have received required training on abuse prevention, neglect, and exploitation upon hire and annually. This was evident for 5 (Geriatric Nurse Assistant GNA# 8, #11, #10, Registered Nurse RN #9, and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed for annual training requirements during the recertification survey. The findings include: On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. On 1/21/2026 at 8:27 AM, a review of the nursing employee records revealed the following: 1. GNA #8 (hired 2/23/24): Completed a 7-item abuse quiz, however, the completion date was not recorded.2. GNA #11 (hired 11/1/22): No evidence of abuse prevention, neglect, and exploitation training upon hire and annually was on file.3. GNA # 10 (hired 3/19/25): Completed a 7-item abuse quiz, however, the completion date was not recorded.4. RN #9 (hired 10/10/23): Completed a 7-item abuse quiz, however, the completion date was not recorded.5. LPN #12 (hired 1/29/24): Completed a 7-item abuse quiz, however, the completion date was not recorded. On 1/21/2026 at 11:19 AM, the DON and the ADON/IP Nurse/ Staff Educator were notified and acknowledged these findings. The ADON/IP Nurse/ Staff Educator stated that the facility does not use an online learning platform, as all training is conducted via face-to-face in-services or classroom sessions. She confirmed that all relevant training documents were stored in individual employee folders and were not available elsewhere in the facility.

Based on record review and interview, it was determined that the facility failed to provide Quality Assessment and Performance Improvement (QAPI) training to staff. This was evident for 5 (Geriatric Nurse Assistant GNA# 8, #11, #10, Registered Nurse RN #9, and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed during the recertification survey. The findings include: QAPI is a Centers for Medicare and Medicaid (CMS) program that merges proactive Performance Improvement (PI) with reactive Quality Assurance (QA). It requires nursing homes to use data-driven, systematic approaches to improve quality of care, resident safety, and overall quality of life. On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. On 1/21/2026 at 8:27 AM, a review of the nursing employee records revealed no evidence of QAPI training for the following staff members:1. GNA #8 (hired 2/23/24)2. GNA #11 (hired 11/1/22)3. GNA # 10 (hired 3/19/25)4. RN #9 (hired 10/10/23)5. LPN #12 (hired 1/29/24) On 1/21/2026 at 11:19 AM, the DON and the ADON/IP Nurse/ Staff Educator were notified and acknowledged these findings. The ADON/IP Nurse/ Staff Educator stated that the facility does not use an online learning platform, as all training is conducted via face-to-face in-services or classroom sessions. She confirmed that all relevant training documents were stored in individual employee folders and were not available elsewhere in the facility.

Based on record review and interview, it was determined that the facility failed to provide mandatory infection prevention and control training to staff upon and hire and routinely thereafter. This was evident for 5 ( Geriatric Nurse Assistant GNA# 8, #11, #10, Registered Nurse RN #9, and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed during the recertification survey. The findings include:On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator.Guideline #16 of the facility's Infection Prevention and Control Program Policy (reviewed/ revised 1/7/25) indicated the following: Staff Education a. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function.b. All staff shall demonstrate competence in relevant infection control practices.c. Direct care staff shall demonstrate competence in resident care procedures established by our facility.However, a review of the nursing employee records on 1/21/2026 at 8:27 AM revealed:1. GNA #8 (hired 2/23/24): No evidence of training on file.2. GNA #11 (hired 11/1/22): No evidence of training on file.3. GNA # 10 (hired 3/19/25): Completed hand hygiene quiz on 6/14/25 and Targeted Infection Prevention Program: Indwelling Urinary Catheter Care, however, the completion date was not recorded. No further evidence of training.4. RN #9 (hired 10/10/23): Completed hand hygiene quiz on 6/9/25 and Targeted Infection Prevention Program: Indwelling Urinary Catheter Care, however, the completion date was not recorded. No further evidence of training.5. LPN #12 (hired 1/29/24): Completed hand hygiene quiz and Targeted Infection Prevention Program: Indwelling Urinary Catheter Care, however, the completion dates were not recorded. No further evidence of training.On 1/21/2026 at 11:19 AM, the DON and the ADON/IP Nurse/ Staff Educator were notified and acknowledged these findings. The ADON/IP Nurse/ Staff Educator stated that the facility does not use an online learning platform, as all training is conducted via face-to-face in-services or classroom sessions. She confirmed that all relevant training documents were stored in individual employee folders and were not available elsewhere in the facility.

Based on record review and interview, it was determined that the facility failed to provide compliance and ethics training to staff. This was evident for 5 ( Geriatric Nurse Assistant GNA# 8, #11, #10, Registered Nurse RN #9, and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed during the recertification survey. The findings include: On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. On 1/21/2026 at 8:27 AM, a review of the nursing employee records revealed no evidence of compliance and ethics training for the following staff members. 1. GNA #8 (hired 2/23/24)2. GNA #11 (hired 11/1/22)3. GNA # 10 (hired 3/19/25)4. RN #9 (hired 10/10/23)5. LPN #12 (hired 1/29/24) On 1/21/2026 at 11:19 AM, the DON and the ADON/IP Nurse/ Staff Educator were notified and acknowledged these findings. The ADON/IP Nurse/ Staff Educator stated that the facility does not use an online learning platform, as all training is conducted via face-to-face in-services or classroom sessions. She confirmed that all relevant training documents were stored in individual employee folders and were not available elsewhere in the facility.

Based on record review and interview, it was determined that the facility failed to provide the required 12 hours of annual in-service training for nurse aides. This was evident for 3 Geriatric Nurse Assistants (GNA# 8, #11, and #10) of 3 randomly selected GNAs reviewed for trainings during the recertification survey. The findings include: On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. On 1/21/2026 at 8:27, a review of the employee records revealed no evidence of training on file for the following GNAs: 1. GNA #8 (hired 2/23/24)2. GNA #11 (hired 11/1/22)3. GNA # 10 (hired 3/19/25) On 1/21/2026 at 11:19 AM, the DON and the ADON/IP Nurse/ Staff Educator were notified and acknowledged these findings. The ADON/IP Nurse/ Staff Educator stated that the facility does not utilize an online learning platform, as all training is conducted via face-to-face in-services or classroom sessions. She confirmed that all relevant training documents were stored in individual employee folders and were not available elsewhere in the facility.

Based on record review and interview, it was determined that the facility failed to provide the mandatory behavioral health training program for all staff members upon and hire and annually. This was evident for 5 ( Geriatric Nurse Assistant GNA# 8, #11, #10, Registered Nurse RN #9, and Licensed Practical Nurse LPN #12) of 5 randomly selected nursing staff reviewed during the recertification survey. The findings include: On 1/16/2026 at 9:11 AM, during an interview with Staff #1, he/she stated that the Assistant Director of Nursing or Infection Preventionist (ADON/IP) Nurse serves as the facility's official Staff Educator. He/she added that staff training upon hire and annually was a collective effort involving the Director of Nursing (DON), the Nursing Home Administrator (NHA), and the ADON/IP Nurse/Staff Educator. On 1/21/2026 at 8:27 AM, a review of the nursing employee records revealed: 1. GNA #8 (hired 2/23/24): No evidence of training on file.2. GNA #11 (hired 11/1/22): Completed a Dementia Overview on 10/21/25; however, there was no evidence of training upon hire or annually.3. GNA # 10 (hired 3/19/25): Records contained quizzes for Dementia (Ethics and Capacity, Palliative/End-of-Life Care, and Middle Stage), but completion dates were not recorded.4. RN #9 (hired 10/10/23): Completed Dementia Overview on 10/21/25 but lacked evidence of annual training. Quizzes for Dementia topics were found without recorded completion dates.5. LPN #12 (hired 1/29/24): Records contained Dementia topic quizzes, but completion dates were not recorded. On 1/21/2026 at 11:19 AM, the DON and the ADON/IP Nurse/ Staff Educator were notified and acknowledged these findings. The ADON/IP Nurse/ Staff Educator stated that the facility does not utilize an online learning platform, as all training is conducted via face-to-face in-services or classroom sessions. She confirmed that all relevant training documents were stored in individual employee folders and were not available elsewhere in the facility.

Based on observations, interview with residents and facility staff, and review of residents' medical records, facility policy, and facility quality assurance and performance improvement (QAPI) material, it was determined that the facility failed to have an effective system in place to prevent cognitively-impaired residents from leaving the facility without adequate supervision. This was evident by the facility's failure to: 1) monitor wander guard placement on Resident #59's person and wheelchair, 2) perform an investigation into Resident #59's first elopement attempt on 9/7/18, 3) prevent Resident #59's second elopement on 10/4/18 for almost 40 minutes in the middle of the night, 4) perform and document staff education following either elopement, and 5) secure or monitor the front door during nighttime hours. This was true for 1 (Resident #59) of 8 residents reviewed for elopement. Elopement is the act of a resident leaving the facility unattended when the resident is physically, mental, or cognitively impaired to the extent that s/he is not safe unaccompanied. A wander guard is a device worn by residents who are at risk for elopement that triggers an alarm or a lock when the resident approaches an armed exit. As a result of these findings, a state of immediate jeopardy was declared on 8/2/2019 at 10:50 AM and was removed on 8/5/2019 at 11:59 AM. The findings include: 1) An investigation into facility reported incident MD 103 was initiated by surveyors on 7/31/2019 at 11:48 AM regarding an elopement by Resident #59 that occurred on 10/4/18. Review of Resident #59's medical record began at this time and revealed that the resident had been admitted to the facility with the [DIAGNOSES REDACTED]. Two physicians had certified that the resident was unable to make his/her own decisions at the time of admission into the facility on [DATE]. Both alcoholic [MEDICAL CONDITION] and Korsakoff syndrome are results of long-term alcohol use. Alcoholic [MEDICAL CONDITION] is a condition in which the liver does not function properly due to long-term damage from alcohol. Korsakoff syndrome is a disorder in which the brain suffers damage due to [MEDICATION NAME] depravation and is exacerbated by the neurotoxic effects of alcohol. Someone suffering from Korsakoff syndrome experiences loss of memory, apathy, and a lack of insight into all aspects of life. Further review of Resident #59's medical record revealed that the resident had an elopement about one month prior to the reported elopement on 10/4/18. The earlier elopement occurred on 9/7/18 and was detailed in the following nurse's note written on 9/7/18 at 11:42 by the then Assistant Director of Nursing, Registered Nurse (RN) #13: Resident out of building on sidewalk area. Agreed to come back in facility and call his/her significant other. Door alarm did not activate when resident exited. Resident's wander guard not present on him/her. New wander guard placed on right wrist and another placed on his/her wheelchair. Found old wander guard on his/her bedside table. RN #13 was interviewed on 8/1/19 at 10:24 AM. During the interview, RN #13 stated that she saw Resident #59 eloping while looking out her office window in the morning of 9/7/18. She recalled that the resident had already exited the facility and was just barely off the property. She stated that she was able to run outside and redirect Resident #59 into the building without resistance. She also recalled placing two wander guards on the resident, one on his/her wrist and the other on his/her wheelchair. When asked if this information was recorded anywhere else in the medical record, she replied that she believed it was not the facility's practice to change care plans or alter orders when a new wander guard, or multiple wander guards, were placed on a resident. Most likely I only mentioned in a progress note that I put a wander guard on the resident's wheelchair. RN #13 indicated that Resident #59's primary clinical staff were involved in returning Resident #59 to his/her room but that it was not her expectation, in her capacity as Assistant Director of Nursing, for the nursing staff to complete an incident report, obtain new orders, or alter care plans. RN #13 reiterated that this event was not considered an elopement by the facility. Review of physicians' orders for Resident #59 revealed that the resident had an order for [REDACTED]. Review of Resident #59's care plan failed to reveal that quantity or locations of wander guards on the resident were specified anywhere. Finally, review of the medical record between 9/7/18 and 10/4/18 (the date of the second elopement) failed to reveal observations of the locations of wander guard units on Resident #59 and his/her equipment. Although nursing documented a wander guard check in Resident #59's Treatment Administration Record (TAR) each shift, the location of the wander guard was not included in any of these observations. Ongoing review of the facility's investigation into Resident #59's elopement on 10/4/19 revealed that the resident eloped early in the morning from the front door of the facility (which was armed with a wander guard alarm panel) while using his/her wheelchair. It was also noted in the investigation that the wander guard alarm panel did not alarm when the resident passed it. However, only one wander guard unit was located after the elopement. Because the quantity and location of wander guard units for Resident #59 were not noted anywhere in Resident #59's medical record after the 9/7/18 elopement, it could not be determined if staff were observing one or two wander guard units on Resident #59 when they performed their inspection every shift and documented in Resident #59's TAR. As a result, staff could not show that they had been assessing for the wander guard unit on Resident #59's wheelchair that had been placed by RN #13 expressly to prevent future elopement given the tendency of the resident to remove his/her wander guard bracelet. 2) Review of Resident #59's medical record on 7/31/19 at 11:48 AM revealed that the resident had eloped twice in (YEAR): on 9/7/18 and on 10/4/18. Review of facility reported incidents sent to the Office of Health Care Quality revealed that only the elopement on 10/4/18 had been reported as an elopement. This was confirmed in interview on 8/1/19 at 9:00 AM with the Director of Nursing (DON), Quality Assurance and Performance Improvement (QAPI) Coordinator, and Assistant Administrator. During the interview, they stated that, because the resident did not leave facility grounds on 9/7/18, they did not consider it an elopement and did not complete an incident report nor send the elopement into the office. Review of the facility's policy regarding elopement revealed the definition of elopement as follows: Elopement is an incident where a resident leaves the facility and he/she is physically, mentally, or cognitively impaired to the extent that she/he is not safe unaccompanied. Any information, investigation, and education that the facility had in relation to this first elopement on 9/7/18 was requested from the facility on 8/1/19 and on 8/2/19. No investigative material or evidence of education performed in relation to this elopement was provided to the survey team prior to survey exit. 3) Review of facility reported incident MD 103 revealed that Resident #59 eloped in the early morning of 10/4/18. The resident was seen by Geriatric Nursing Assistant (GNA) #5 traveling past the North Hall nurse's station via wheelchair at 1:40 AM. At 1:50 AM, because of a strange noise, Licensed Practical Nurse (LPN) #9 went to the front door to investigate and found the door propped open by a rug. The strange noise revealed itself to be the air conditioning unit blowing into the facility while the front door was continually propped open. A search of the facility began and Resident #59 was discovered to be missing from the facility at 1:59 AM. The resident was located outside the facility on a different street than where the facility was located. The resident had been spotted by police and was returned to the facility accompanied by police at 2:20 AM. The resident's wheelchair was found outside, discarded by the resident under a nearby tree. The wheelchair did not have a wander guard unit attached to it. It was noted in the investigation that the wander guard alarm did not sound and that a single wander guard bracelet was found in a cup of water in Resident #59's room after the elopement. It was not clear if this bracelet had been on the resident's wrist or the resident's wheelchair. The resident was assessed by nursing upon return to the facility and by a physician later that morning and no injuries were noted as a result of this elopement. This review of the incident revealed that the facility reported this elopement to family, physician, county ombudsman, and state agency. Resident #59's medical record was reviewed on 7/31/19 at 11:48 AM. The review revealed an order dated 9/2/18 with the instructions, Resident with wander guard on at all times and was ordered to be performed every shift. This order was renewed on 9/17/18 with no additional instructions. Another order was found with the date 9/5/18 that stated, monitor target behaviors: non-compliance, argumentative, unsafe wandering, paranoia. Monitor every shift. The care plan topic of Falls was found dated 9/2/18 that stated, Resident is at risk for falling related to poor cognition and understanding of safety risks, that included the approach, Teach resident safety measures. Finally, an order for [REDACTED]. Ongoing review of the medical record revealed that, following the resident's elopement on 9/7/18, three care plan areas were initiated. The first, initiated on 9/7/18, was Ineffective coping related to situation crises, and included the approach, Assess if ineffective coping endangers the resident and/or others. Intervene as necessary. The second, initiated on 9/12/18, was Resident resists care related to not wearing cervical collar and not waiting for assistance with ambulation, and included the approach, Establish clear boundaries for the resident. The third, initiated on 9/17/18, was Elopement: Resident experiences wandering, and included the approaches, Equip resident with a device that alarms when wanders; check for proper functioning of device every shift, and, provide care, activities, and a daily schedule that resembles the resident's prior lifestyle. No care plan topic, assessment, or intervention was found that addressed the resident's ability to remove his/her wander guard bracelet. An interview was conducted with GNA #5 on 8/1/19 at 2:41 PM. During the interview, GNA #5 stated that she did recall Resident #59's elopement in the early morning of 10/4/2018. She confirmed that she observed the resident traveling in his/her wheelchair past the nurse's station in the Front Hall while GNA #5 completed documentation on the computer. When asked if she spoke with the resident, she stated, no, I didn't. She stated that Resident #59 would regularly travel the halls at night to get some coffee or talk to staff on the other unit, and that she didn't think anything of the resident passing by. GNA #5 recalled that only one wander guard unit could be found that night, but that it was found in a glass of water in the resident's room. When asked if the resident required supervision when moving about the facility via wheelchair, GNA #5 stated, No. Finally, when asked if any formal education had been provided to her following the incident, GNA stated that she had been asked to write a statement about the situation and some lessons were learned, but she stated that she had not received formal education following that elopement. When asked to elaborate on what 'some lessons' were, she stated, we just had to keep better eyes on him/her. An interview with the Quality Assurance and Performance Improvement (QAPI) Coordinator was performed on 7/31/19 at 3:07 PM. During the interview, the QAPI Coordinator stated that a Performance Improvement Project (PIP) had been performed by the facility regarding elopement that followed Resident #59's second elopement. The QAPI Coordinator stated, We thought one of the problems might be alarm fatigue. We also wondered if during the admission assessment, if they were capturing the elopement risk. We want to ask families about elopement risk and document events that lead to elopement like 'I want to go home.' We provided education to staff and wander guards are checked every day by nursing. So the four things we did were adjust the wander guard system to produce less false alarms on 10/11/2018, perform elopement risk assessment at admission, increase nursing documentation, and begin monthly tracking of elopement. We also began elopement drills and the first was done on 6/26/2019. The PIP materials were shared with the survey team at this time. The PIP documented the Date Identified as being 10/1/2018, although it can be seen that 10/16/18 was scratched out. The 'Goal / Objective' was, Resident Safety - Confused resident have supervision leaving building. The 'Issues Identified' was, 1) [NAME] / Alarm Fatigue - increased noise. 2) Admission Assessment not triggering Risk of Elopement. The 'Actions' were, 1) Leadership meeting to discuss alarms - decrease sound frequency. 2) QA Admission Elopement Risk. 3) Nursing document events possibly leading to increased elopement risk. 4) Monthly tracking elopement events - begin now. Due to the 'Date Identified' being documented as 10/1/2018, prior to Resident #59's elopement on 10/4/2018, the QAPI Coordinator was asked to clarify if this PIP was done in response to Resident #59's elopement or not. The QAPI Coordinator stated, yes, this was in response to Resident #59's elopement on 10/4/2018. The QAPI Coordinator could not identify any quality changes that were made as a result of the first elopement, however did state that she believed a second wander guard was placed on the resident after the first elopement. The QAPI Coordinator provided the survey team with a nursing note that had been written at the time of the first elopement that stated wander guards had been placed on both the resident's right wrist as well as on the resident's wheelchair. When asked how both wander guard bracelets were being tracked, the QAPI Coordinator could not provide any further documentation of how both were being tracked. 4) Interviews were performed with nursing staff including Licensed Practical Nurses (LPNs) #6, #8, and #12 as well as GNAs #2 and #5 on 7/31/2019 around 2:45 PM. Staff were interviewed on the units they were working on. All five staff were asked when they had most recently received elopement inservice training. None could recall when they had their most recent formal training but they did recall that an elopement drill had been performed in April, 2019. LPN #6 and #8 stated that the elopement training had gone well. Following her presentation of the elopement PIP on 7/31/2019 at 3:07 PM, the QAPI Coordinator was asked to provide any evidence of the staff education that she had indicated was given following Resident #59's second elopement. None was provided. An interview was performed on 8/1/19 at 9:00 AM with the Director of Nursing (DON), QAPI Coordinator, and Assistant Administrator. During the interview, it was asked if any education had been provided to facility staff following either of Resident #59's elopements. These facility staff stated that, because the resident did not leave facility grounds, they did not consider the events on 9/7/2018 to be an elopement and did not complete an incident report nor did they perform any staff education regarding the elopement. The DON was unsure at that time if staff education had been performed after Resident #59's second elopement on 10/4/2018. The survey team requested any education to be provided as soon as possible for review. The DON was asked again by the survey team on 8/1/2019 at 11:08 AM to provide any evidence of staff education following Resident #59's elopements. An 'Inservice Attendance Sheet' attached to the facility's elopement policy was given to the survey team at 12:05 PM. However, the date of the inservice was 4/16/2018 and 4/17/2018. 5) Review of the facility's investigation into Resident #59's second elopement revealed the statement, On 10-5-2018 an alarm was placed on front door. This alarm will be turned on each evening around 8 PM and turned off around 7 am. This alarm will be activated any time the door is opened during these hours. An observation of the front door alarm was made on 7/31/2019 at 1:55 PM. The alarm was a small white magnetized box that detected when the door was opened. It was found to make a chiming sound when the door was opened during the day although it could not distinguish if anyone walked through the door. Receptionist #7 was interviewed at the same time and she demonstrated the second, 'Alarm' setting by switching the setting on the white box. This setting made a louder, shriller tone that continued until the door closed. Receptionist #7 stated that the receptionists worked from 7:00 AM to 8:00 PM and that the front door was not monitored when a receptionist was not working. Receptionist #7 also said that the receptionists were responsible for switching the setting from Chime to Alarm each evening at 8:00 PM, as well as for disabling the handicap button that opens the front door automatically. Both are switched back when the receptionist arrives in the morning. Receptionist #7 also indicated that the wander guard alert system was a separate system and alarmed when a resident wearing a wander guard approached the front door. The facility's two nurses' stations were noted to be around 2 corners from the front door. It was noted that the front door alarm could be heard faintly from either nursing station while in both Chime and Alarm modes. However, there was no visual or auditory signal at either nurses' station when the front door alarm went off. The wander guard system was noted to create a local alarm and illuminate a light at both nurses' stations when it was activated. During an interview with the Acting Director of Maintenance that took place on 8/1/2019 at 12:57 PM, the Acting Director stated that the alarm on the front door was installed in March, 2019, five months after Resident #59's elopement on 10/4/2018. The Acting Director of Maintenance stated that he performs monthly reviews of the whole wander guard system to ensure that it is functioning correctly and that there have been no problems with it in either (YEAR) or 2019. The Acting Director of Maintenance clarified that his reviews involve verifying that the system alarms correctly when a wander guard unit is nearby. During a walk-through with the Administrator that took place on 8/2/2019 at 11:30 AM, the Administrator stated that there was another alarm system that hadn't been reviewed yet by the survey team. He referred to a House Alarm System (separate from the white front door alarm described above) that alarmed locally at the nurses' stations with sound and visual indicators when any of the external doors were opened. This was tested with an emergency exit at the end of the North Hall and it was confirmed that both sound and visual indicators activated at the nurses' station. The Administrator then stated this House Alarm system was also armed at the front door during the night. The walk-through continued to the front door where the Administrator indicated the keypad used to silence the wander guard system when it activated. The Administrator stated that this keypad was used to arm the front door with the House Alarm system each night. The receptionist, who was present at the time, then stated that she does not use that keypad to enable any house alarm. The Administrator then went to the Front Hall nurses' station and attempted to arm the House Alarm at the front door there. He was unable to do so but suggested that this is something that can be investigated. This House Alarm system was not enabled by the time surveyors exited the facility on 8/5/2019 at 12:00 PM, however the white Front Door Alarm and the wander guard systems were still functional. ~~ As a result of these findings, a state of immediate jeopardy was declared on 8/2/2019 at 10:50 AM and the facility was provided with the Immediate Jeopardy Template at that time. The facility submitted a removal plan on 8/2/2019 at 1:18 PM and the State Agency was unable to accept this plan. The facility submitted additional plans at 2:45 PM, 4:21 PM, and 4:46 PM. The facility removal plan was accepted by the State Agency at 4:54 PM. The immediate jeopardy was removed on 8/5/2019 at 11:59 AM. The facility's abatement plan included the following provisions: - Facility staff to be immediately inserviced including nursing, administration, housekeeping, dietary, maintenance, and activities staff regarding the elopement policy, the wander guard policy, monitoring residents at risk for elopement, interventions to prevent elopement, and responding to alarms. This education will be performed by the Staff Development Nurse. - No staff can begin a shift without first receiving the above training. - A schedule will be maintained of all staff who have yet to receive training to ensure that they all receive the training as soon as is practicable. - A response log will be maintained at the front desk that staff must complete when they respond to the local alarm on the facility's front door. - Residents who are at risk for wandering will have a yellow wristband instead of a white wrist band. - Location checks will be performed every 30 minutes for 24 hours for residents after an elopement has occurred. - Care plans will be updated after an elopement to reflect any new interventions. - Alleged date of compliance: 8/4/2019.

Based on observation, medical record review, interviews with the Assistant Administrator, Acting Director of Nursing, and facility staff it was determined that the facility failed to put an effective safety plan in place for all residents and facility staff after a resident (Resident #1) was accused of an assault and sex offense of a facility staff member. As a result of these findings an Immediate Jeopardy was called at 4:00 PM on May 16th, 2017. The findings include: Review of Resident #1's medical record revealed that he/she was admitted to the facility on [DATE] for rehabilitation following a stroke. Review of a neurologist consultation on 2/23/17 revealed the physician diagnosed the resident with organic brai[DIAGNOSES REDACTED] with behavioral features that included lack of inhibition and fits of uncontrollable rage. Review of the resident's occupational and physical therapy notes for 5/3/17 and 5/4/17 revealed the resident had the ability to stand unassisted for 1-2 minutes and ambulate using a wheeled walker 250 feet unassisted. During the time at the facility he/she exhibited the following aggressive behavioral incidents that were documented in the medical record: A. On 2/1/17 the resident hit a physical therapist with a shoe. B. On 2/6/17 the resident was in the kitchen opening cart doors looking for food. C. On 2/6/17 the housekeeping staff reported resident was urinating in sink. D. On 2/10/17 during therapy the resident stated to another resident about a therapist why don't you just hit him in the face with a shoe E. On 2/13/17 the resident took the bedside dresser from the roommate side of the room and moved it to his/her side. F. On 2/16/17 the resident attempted to kick a nursing assistant. G. On 2/19/17 the resident asked a nursing assistant for a gun. At that time the resident was sent for a mental health evaluation and returned to the facility. H. On 2/22/17 the resident told a nursing assistant he/she would stab her with a knife. I. On 2/24/17 the resident was engaged with himself unclothed with door open. J. On 2/25/17 the resident removed his/her pull ups several times and refused to keep gown on. K. On 2/26/17 the resident is lying in bed without clothes. L. On 2/28/17 the resident was found in the dining room alone with no pants on. M. On 2/28/17 the resident stated to staff about his/her roommate Good let him die, drown him N. On 3/8/17 the resident is in bed unclothed with curtain open to roommate. O. On 3/9/17 the resident has been noted to take food off other residents trays. P. On 3/18/17 the resident is found in dining room alone with no pants on and when staff told him/her it was inappropriate resident looked at staff and stated bullet, bullet, bullet. Resident then looked at receptionist and said I can't use the word G-U-N Q. On 5/2/17 the resident smacked the buttocks of an occupational therapist. On 5/9/17 the resident was accused of sexually assaulting a facility staff member. Review of the medical record revealed the resident was seen by his/her physician on 5/10/17 at 7:23 AM and the physician documented at that time I was notified about his yesterday's aggressive behavior. After discussion with charge nurse and Administrator, I deemed he is at high risk to harm other frail patients and staffs. He needs to be discharge from this facility. Review of the facility's investigation of the incident revealed that the resident was charged with a second degree assault and fourth degree sexual offense on 5/11/17, as a result of the 5/9/17 sexual assault on a facility staff member. During interview with the Assistant Administrator and Acting Director of Nursing on 5/16/17 at 11:00 AM, they stated after the incident occurred the facility staff moved the resident's roommate, monitored resident's behaviors, issued the resident an involuntary discharge, instructed 2 staff members to assist with resident at all times and had facility staff to perform checks of the resident every 30 minutes. Further review of the medical record revealed no safety care plan for the resident, no documentation of 30 minute checks and no documentation of the need for 2 staff members to assist resident at all times. Interview with the Acting Director of Nursing on 5/16/17 at 11:00 AM revealed that the 30 minute checks had not begun. The facility staff began 30 minute checks of the resident on 5/16/17 at 11:30 AM after surveyor intervention. In addition, observation of the resident on 5/16/17 at 10:37 AM by the surveyor revealed the resident to be in his bed sleeping. At that time, no staff were observed in the hallway or near the resident's room which potentially gives the resident the ability to leave his room unobserved by staff which could lead to the potential for harm to staff and/or other residents. The facility developed a plan suffucient to remove immediacy which was reviewed and accepted on May 16, 2017 at 6:30 PM while the surveyor remained onsite. The Plan of Correction included: 1. Resident #1767-01 will have 1 on 1, 24 hour supervision by facility paid individual. Individual to sit outside of Resident #1767-01 room and not allow him to go into another resident room. 2. Staff to chart on a Q 30 minute check off sheet Resident #1767-01 behaviors or lack of behaviors. Check off sheet will then be scanned into electronic medical record chart. 3. Nurse to chart every shift on Resident #1767-01 behaviors of absence of behaviors in the electronic medical record. 4. The Medical Director will visit Resident #1767-01 once a week for 90 days to evaluate behaviors, current status, and overall condition and document findings in the electronic medical record. The Medical Director will evaluate Resident #1767-01 after 90 days to determine if every 30 day visit will be sufficient to resume. 5. Process will be developed with staff to be educated on actions to be taken in the event of aggressive, physical, verbal, or sexual behaviors by Resident #1767-01. All staff to be educated by 5/17/2017. 6. Staff, also, to be educated that Resident #1767-01 is to have 2 person assist with all care directly and indirectly by 5/17/2017. 7. Care plan to be updated to include all new interventions addressed in this plan of correction.

Based on medical record review and interview with the Medical Director and the Director of Nursing, it was determined the medical and nursing and staff' failed to: 1) allow resident's who are capable, to make their own choices regarding end of life treatment choices, 2) establish an effective process to ensure that residents' or residents' proxy's (health care agent or surrogate decision maker) end of life wishes were honored and 3) failed to establish an effective system to recognize and correct discrepancies. This was evident for twelve residents (#10, #15, #32, #39, #46, #50, #54, #63, #70, #74, #84 and #96) of 69 medical records reviewed for Advanced Directives. This had the potential to effect all of the facility residents. A certificate of incapacity determines the resident's ability to make decisions regarding care and treatment, to evaluate risks/benefits of care/treatments, understand and sign documents and effectively communicate decisions. By Maryland State law, 2 certificates of incapacity are required when an individual is determined to lack capacity. In addition to this, after two physician evaluations, the resident must be declared to be in one of the three following conditions; persistent vegetative, end stage or a terminal condition for the appointed health care agent or surrogate to change the resident's code status from a full code to a DNR or do not resuscitate. DNR means no attempts would be made to assist the resident in the event his/her heart should stop or he/she was not breathing. A physician may also make a resident a DNR if CPR would be deemed Medically Ineffective, meaning no desired results would be produced by resuscitation. A MOLST form (Maryland Medical Orders for Life-Sustaining Treatment) is a state document that includes medical orders regarding resuscitation and other life sustaining treatment options such as, but not limited to, blood [MEDICAL CONDITION], diagnostic tests or antibiotic use. The facility's, Policy for MOLST was reviewed and noted to outline a procedure regarding the completion of a MOLST form, as well as, reviewing and revising a MOLST form. On [DATE], during an interview with the DON and Assistant Director of Nursing (ADON), the DON stated she wrote the facility policy and further acknowledged that she was not following the procedure. During an interview conducted on [DATE] at 4:15 PM, both the Medical Director and Director of Nursing (DON) stated they did not know that the facility must obtain 2 certificates of incapacity and in addition that a resident must meet one of the 3 conditions listed above before the health care agent or surrogate would have the authority to change the code status from a full code to a DNR. The DON further stated it is the responsibility of the registered nurses to complete the MOLST form, obtain any related documents, such as, Advanced Directives or a living will and any certificates of incapacity. All paperwork would then be placed in the chart for physician review. The facility's failure to ensure that residents' end of life wishes were honored placed all residents at risk and the findings resulted in an Immediate Jeopardy. The Immediate Jeopardy was called on [DATE] at 3:30 PM. A Plan of Correction was submitted indicating the 12 medical records were reviewed and corrected and training was provided to staff. The Immediate Jeopardy was abated on [DATE] at 8:15 PM. The findings include: 1. The physician failed to review Resident # 32's Power of Attorney for Health Care and allow the resident to make his own end of life decisions. Resident # 32 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident is described as alert and oriented, can perform activities of daily living (ADL) with minimal assist from staff and can make his needs known. Review of the medical record revealed that the resident transferred from another facility where the resident was a full code. Continued review of the medical record, the MOLST form, revealed the resident's health care agent made the resident a DNR at the time of admission to the facility. Further review of the medical record revealed the following; no certificates of incapacity were obtained, the resident had a Power of Attorney for Health Care appointing the spouse the health care agent and that the Power of Attorney for Health Care would take effect when the resident was unable to make his own choices and lastly the resident was deemed capable by the attending physician on [DATE]. The facility failed to honor the resident's Power of Attorney for Health Care before allowing the health care agent to change the resident's code status from a full code to a DNR and failed to review the MOLST form or have a discussion with the resident regarding end of life treatment options once the resident was deemed capable on [DATE]. The resident was interviewed on [DATE] and stated he desired to be a full code. The MOLST form was then changed making the resident a full code. 2. The physician failed to ensure that the required certificates of incapacity were obtained before allowing Resident # 50, # 54 and # 96's health care agent or guardian to make choices regarding end of life treatment options. Resident # 50 was admitted with [DIAGNOSES REDACTED]. Review of the MOLST form revealed the resident was made a DNR by the resident's guardian on [DATE]. Further review of the medical record revealed multiple certificates of incapacity signed by two physicians between 2011 and 2014 for dementia, progressive dementia and alcoholic dementia but none for end stage. A physician's note, dated [DATE], stated the following, "I spoke with (the resident's guardian) and MOLST form signed; DNR. Pt is NOT-CAPABLE to take health & financial decision". The medical record was reviewed by the physician and the resident was made a full code on [DATE]. Resident # 54 was admitted with [DIAGNOSES REDACTED]. Review of the MOLST form revealed the resident was made a DNR by the resident's guardian on [DATE]. Further review of the medical record revealed one certificate of incapacity for dementia dated [DATE]. The medical record was reviewed by the physician and the resident was made a full code on [DATE]. Resident # 96 was admitted with [DIAGNOSES REDACTED]. Review of the MOLST form revealed the resident was made a DNR by the resident's health care agent on [DATE]. Further review of the medical record revealed one certificate of incapacity for dementia dated [DATE]. Continued review of the medical record revealed a copy of the resident's Advanced Directives stating that the determination of incapacity shall be made by the attending physician and a second physician or licensed clinical psychologist after a personal examination and that such certificates shall be required before treatment is withheld or withdrawn. The resident was re-evaluated and the second certificate of incapacity for end stage dementia was obtained on [DATE]. The resident remained a DNR. 3. The facility staff failed to allow Resident #74 to make his own end of life decisions. Resident #74 is alert and oriented and has not been deemed incapable of making his own end of life decisions. Review of the medical record revealed a Maryland Medical Orders for Life Sustaining Treatment (MOLST) form signed by the physician on [DATE] stating that the resident was to not have cardiopulmonary resuscitation (CPR). The no CPR decision was made as a result of a discussion with and the informed consent of "the patient's health care agent as named in the patient's advance directive". Review of the medical record revealed that the resident had named his daughter as his financial power of attorney but had not named anyone as his healthcare power of attorney. Further review of the medical record revealed a Living Will signed by the resident on [DATE] that stated his end of life wishes that were to take effect when two physicians had certified him as being in a terminal condition. Review of the medical record revealed no physician certifications that the resident is in a terminal condition. The facility staff allowed the resident's daughter to make end of life decisions for this resident who was deemed capable of making those decisions for himself. 4. The facility staff failed to obtain two physician certifications of incapacity before allowing the health care agent to make end of life decisions for Resident #39. Review of the medical record revealed a MOLST form signed by the physician on [DATE] stating that the resident was not to have CPR. Review of the medical record revealed that Resident #39 had an Advance Directive signed by the resident on [DATE] that named a health care agent to make end of life decisions once the resident had been certified by two physicians to be incapable of making her own decisions. Further review of the medical record revealed only one physician certification of incapacity. Upon surveyor intervention on [DATE], a second physician examined the resident and certified her as incapable of making her own decisions. Review of the medical record revealed that the facility staff spoke with the health care agent and verified the end of life decisions listed on the MOLST form. 5. The facility staff allowed a "guardian of the person" to make end of life decisions when Resident #70 had not been deemed incapable or end-stage, persistent vegetative or terminal by any physician. Review of the medical record revealed a MOLST form signed by the physician on [DATE] stating the resident was not to have CPR as a result of a discussion with and the informed consent of "the patient's guardian of the person". Further review of the medical record revealed no Advanced Directive naming a health care agent nor a court document naming a guardian of the person. Review of the medical record revealed no physician certifications of incapacity and no certifications of end-stage, persistent vegetative or terminal. Upon surveyor intervention on [DATE], two physicians certified the resident as incapable and end-stage thereby giving the authority to the son to make end of life decisions for this resident. The facility staff verified with the son that the resident was to remain a no CPR. 6. The facility staff allowed a health care agent to make end of life decisions for Resident #63 without two physician certifications of incapacity. Review of the medical record revealed a MOLST form signed by the physician on [DATE] stating the resident was not to have CPR as a result of a discussion with and the informed consent of "the patient's health care agent as named in the patient's advance directive". Further review of the medical record revealed an Advanced Directive signed by the resident on [DATE] giving her health care agent authority to make end of life decisions when two physicians certify the resident of incapable of making her own decisions. Review of the medical record revealed only one physician certification of incapacity. Upon surveyor intervention on [DATE], two physicians assessed the resident and deemed her incapable of making health care decisions. The facility staff spoke with the health care agent who made the decision for CPR. 7. The facility staff allowed Resident #100's sister to make end of life decisions without two physician certifications of incapacity and end-stage, persistent vegetative or terminal. Review of the medical record revealed a MOLST form signed by the physician on [DATE] stating the resident was not to have CPR as a result of a discussion with and the informed consent of "the patient's guardian of the person or the patient's surrogate". Further review of the medical record revealed no Advanced Directive naming a health care agent nor a court document naming a guardian of the person. Review of the medical record revealed on [DATE] only one physician deemed Resident #100 as incapable of making health care decisions. Further review of the medical record revealed no certifications of end-stage, persistent vegetative state or terminal condition. The Health Care Decisions Act require that two physicians deem an individual incapable of making health care decisions AND end-stage, persistent vegetative or terminal before a surrogate can make end of life decisions. Upon surveyor intervention, the physician reassessed the resident and found her to still be incapable of making health care decisions. However, the physician's assessment did not find the resident in an end-stage, persistent vegetative or terminal condition. On [DATE] Resident #100's MOLST form was changed to a full code. The facility staff's failure to follow the Health Care Decisions Act by allowing a "surrogate" to make end of life decisions put Resident #100 at risk for not having CPR in the event of cardiac and/or respiratory arrest. 8. The facility staff failed to obtain all necessary certifications before allowing a resident's daughter to make end of life decisions. Resident #84 was admitted to the facility with multiple [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident had no advance directive in place for end of life decisions. Further review of the medical record revealed only one physician had deemed the resident incapable of making any health care decisions including end of life decisions on [DATE]. Continued review of the medical record revealed that two physicians had not certified the resident as end stage, persistent vegetative or in a terminal condition. The resident, at this time, was a "Full Code". A Full Code is to initiate CPR in the event of [MEDICAL CONDITION]. Review of the "Maryland Medical Orders for Life Sustaining Treatment" (MOLST) form revealed that on [DATE], the resident's "Surrogate" had changed the resident's code status from a Full Code to a Do Not Resuscitate (DNR). A DNR is an order to not perform Cardio [MEDICAL CONDITION] Resuscitation (CPR). A MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation (CPR) and other life sustaining treatment options. At this time, the physician reviewed and signed the MOLST form. The facility staff allowed the resident's daughter to act as a surrogate and make end of life decisions for the resident, even though the necessary certifications were not in place. According to the Health Care Decisions Act, if the individual has not picked a healthcare agent and is no longer able to make health care decisions a surrogate has authority to make these decisions. Before the surrogate is given authority to make end of life decisions, two physicians must determine that the individual is incapable of making healthcare decisions and has a terminal or end-stage condition or is in a persistent vegetative state. Interview with Director of Nursing (DON) on [DATE] at 1:40 PM verified that the necessary certifications were not obtained prior to giving the daughter the authority to make end of life decisions for the resident. After surveyor intervention, two physicians evaluated the resident on [DATE] and had deemed the resident incapable and certified the resident was in an end-stage condition. Now the daughter can make all health care decisions, including end of life decisions, for this resident. 9. The facility staff failed to obtain all necessary certifications before allowing a resident's daughter to make end of life decisions and failed to follow the resident's wishes in her Living Will. Resident #46 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the medical record revealed that the resident had a Living Will dated [DATE]. It stated that if at any time the resident had an incurable injury, disease or illness certified to be terminal by two physicians (one being her attending) and that the physicians have determined that death is imminent and will occur whether or not life sustaining procedures are utilized the resident then directed for life sustaining procedures to be withheld or withdrawn including artificial hydration and nutrition. Review of the "Maryland Medical Orders for Life Sustaining Treatment" (MOLST) form revealed that on [DATE], the resident's "Surrogate" had made end of life decisions for the resident even though the resident had been deemed capable of making her own decisions. Also, the resident's Living Will was not being honored because the resident had stated that she had wanted two physicians to determine she was terminal or had an incurable injury, disease or illness before implementing life sustaining procedures to be withheld or withdrawn. Further review of the medical record revealed the resident had another MOLST form completed on [DATE]. Again the resident's surrogate made end of life decisions even though the resident had not been deemed incapable by two physicians, nor had the resident been certified to be end stage, persistent vegetative or in a terminal condition by two physicians. Due to the resident still not being determined as terminal or having an incurable injury, disease or illness was not following the resident's wishes in her Living Will. According to the medical record the resident's health had been declining physically and cognitively and was diagnosed with [REDACTED]. Continued review of the medical record revealed that, even though the surrogate was making end of life decisions, two physicians had not deemed the resident incapable nor had two physicians determined the resident was end stage, persistent vegetative or in a terminal condition. After surveyor intervention, two physicians evaluated the resident on [DATE] and had deemed the resident incapable and had also certified the resident to be in an end-stage condition. End Stage, as stated on the MOLST form is an advanced, progressive, irreversible condition injury, disease or illness that has resulted in severe and permanent deterioration indicated by incompetency and complete physical dependency, and for which, to a reasonable degree of medical certainty, treatment of [REDACTED]. Now the daughter not only can make all health care decisions, including end of life decisions, for this resident, but the resident's wishes in her Living Will were now also being followed. 10. The facility staff failed to acknowledge that the resident was able to make her own end of life decisions. Resident #15 was admitted to the facility with multiple [DIAGNOSES REDACTED]. According to the medical record the resident required minimal assistance from the facility's staff for care, comfort and safety. Review of the medical record revealed that the resident had no advance directive in place for end of life decisions. Review of the "Maryland Medical Orders for Life Sustaining Treatment" (MOLST) form revealed that on [DATE], the resident's health care agent as stated in the resident's advance directive was making end of life decisions including Do Not Resuscitate (DNR). A DNR is an order to not perform Cardio [MEDICAL CONDITION] Resuscitation (CPR). A MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding CPR and other life sustaining treatment options. At this time, the physician reviewed and signed the MOLST form. The facility staff allowed the resident's grandson to act as a health care agent and make end of life decisions for the resident, even though the resident had no advance directive which appointed a health care agent. Interview with the Social Worker on [DATE] at 1:10 PM verified that the resident did not have an advance directive. After surveyor intervention, two physicians evaluated the resident on [DATE] and had deemed the resident capable of making her own decisions. The resident changed her code status from DNR to Full Code. A Full Code is to initiate CPR in the event of [MEDICAL CONDITION].

Based on medical record review and interview with the Medical Director, it was determined the Medical Director failed to ensure that an effective process was in place to obtain and review for completeness all required pertinent documentation to ensure that residents' or residents' proxy's (health care agent or surrogate decision maker) end of life wishes were honored. This was evident for twelve residents (#10, #15, #32, #39, #46, #50, #54, #63, 70, #74, #84 and #96) of 69 medical records reviewed for Advanced Directives. This had the potential to effect all the facility residents. The findings include: The Medical Director is responsible for physician and clinical leadership, assisting the facility in establishing systems and methods related to the delivery of quality care and services, including participation in the development of policies regarding the protection of resident rights, advanced care planning and other ethical issues, and promotes a learning culture that includes education, information and communication. A certificate of incapacity determines the resident's ability to make decisions regarding care and treatment, to evaluate risks/benefits of care/treatments, understand and sign documents and effectively communicate decisions. By Maryland State law, 2 certificates of incapacity are required when an individual is determined to lack capacity. In addition to this, after two physician evaluations, the resident must be declared to be in one of the three following conditions; persistent vegetative, end stage or a terminal condition for the appointed health care agent or surrogate to change the resident's code status from a full code to a DNR (Do Not Resuscitate). DNR means no attempts would be made to assist the resident in the event his/her heart should stop or he/she was not breathing. A physician may also make a resident a DNR if cardiopulmonary resuscitation (CPR) would be deemed Medically Ineffective, meaning no desired results would be produced by resuscitation. A MOLST form (Maryland Medical Orders for Life-Sustaining Treatment) is a state document that includes medical orders regarding resuscitation and other life sustaining treatment options such as but not limited to blood [MEDICAL CONDITION], diagnostic tests or antibiotic use. During an interview conducted on [DATE] at 4:15 PM, the Medical Director stated he did not know that the facility must obtain 2 certificates of incapacity and in addition that a resident must meet one of the 3 conditions listed above before the health care agent or surrogate would have the authority to change the code status from a full code to a DNR. In this facility the Medical Director also serves as an attending physician. The Medical Director's failure to ensure that an effective process was in place for Advanced Directives placed all residents at risk and the findings resulted in an Immediate Jeopardy. The Immediate Jeopardy was called on [DATE] at 3:30 PM. A Plan of Correction was submitted indicating the 13 medical records were reviewed and corrected and training was provided to staff. The Immediate Jeopardy was abated on [DATE] at 8:15 PM. Cross reference to F 155.

Based on medical record review and interviews with staff, it was determined the nursing staff failed to notify the physician of [MEDICAL CONDITION] activity (jerking movements) that continued despite intermittent interventions of medications administered via injection in one (Resident #3) of three medical records reviewed. The findings included: Resident #3 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the medical record revealed physician orders [REDACTED]. [MEDICATION NAME] is an [MEDICAL CONDITION] medication. Rapid discontinuation of [MEDICATION NAME] increases the risk of [MEDICAL CONDITION] activity. A [MEDICAL CONDITION] is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations. [MEDICAL CONDITION] is a condition characterized by recurrent [MEDICAL CONDITION] that may include repetitive muscle jerking called convulsions. Further review of the medical record revealed that the nursing staff administered orally 1000mg of [MEDICATION NAME] to the resident at 9:00AM on 07/18/14 as ordered by the physician. Review of the medical record revealed the following nurses' notes: On 07/18/14, a nurse wrote that the resident was noted as non responsive with tremors of the upper extremities (arms). The physician was notified and ordered a one time dose of [MEDICATION NAME] 5mg to be administered via injection into the muscle (IM). The [MEDICATION NAME] was administered in the left deltoid (upper arm muscle) at 9:15AM per the Medication Administration Record [REDACTED] [MEDICATION NAME] is a minor tranquilizer that prevents or stops [MEDICAL CONDITION] by slowing down the central nervous system. [MEDICATION NAME] is not usually the first choice for long-term treatment of [REDACTED]. On 07/18/14 at 9:30AM, a nurse wrote that the resident was sluggish, but verbally not present, unable to communicate and lying in recliner. A common side effect of [MEDICATION NAME] is drowsiness or sedation. On 07/18/14 at 2:40PM, a nurse wrote that the physician was updated that afternoon for continued increased heart rate and lethargy. The physician was notified that the resident was not able to take fluids or solids by mouth. The physician gave an order for [REDACTED]. On 07/18/14 at 7:55PM, a nurse wrote that the resident was unable to eat supper and had been unresponsive during the shift. Oral medications were held as ordered. No [MEDICAL CONDITION] activity at this time. Review of the medical record revealed that the physician examined the resident on 07/19/14. Review of the physician progress notes [REDACTED]. The physician wrote "patient remains confused but no pain (or) distress...patient had decreased mental alertness yesterday". The physician wrote "will continue supportive care and pain management for pelvic fracture". Further review of the medical record revealed the following nurses' notes: On 07/19/14 at 2:15PM, a nurse wrote that the patient was alert and verbal yet unable to understand the resident's speech. The resident refused her medications. The resident's daughter was in to visit. On 07/19/14 at 10:00PM, a nurse wrote that the resident was up in a recliner for a while. And noted to have frequent involuntary body movements of both arms. The resident refused supper and liquids and all medications. Review of the MAR indicated [REDACTED]. Review of the medical record revealed that the nursing staff did not notify the physician that the resident was having "frequent involuntary body movements of both arms". On 07/20/14 at 5:00AM, a nurse wrote that the resident rested in bed all PM. Fluids offered resident who only took small sips. The resident continued to have involuntary jerking movements of her extremities (arms and legs). Review of the medical record revealed that the nursing staff did not notify the physician of the continued involuntary jerking movements. Review of the MAR indicated [REDACTED]. On 07/20/14 at 11:30AM, a nurse wrote that the resident was noted to have right sided twitching to arm and leg. The physician was made aware and ordered 5mg of [MEDICATION NAME] to be administered via injection into the muscle. Review of the MAR indicated [REDACTED]. This is the first physician notification and intervention for [MEDICAL CONDITION] activity attempted since the nursing staff began documenting the continued involuntary jerking movements for approximately 12 hours beginning at 10:00PM on 07/19/14. Interview at 2:30PM on 07/30/14 with nurse #1 who administered the [MEDICATION NAME] on 07/20/14 revealed that the involuntary jerking began again at approximately 2:30PM on 07/20/14. Nurse #1 went on to state that she notified the physician of the return of the jerking movements and the physician ordered 25mg of [MEDICATION NAME] to be given via injection. [MEDICATION NAME] is sometimes used to stop [MEDICAL CONDITION] activity. Review of the report sheet dated 07/20/14 revealed that the 3PM-11PM shift nurse documented that the tremors decreased after the [MEDICATION NAME] was administered, however, the tremors continued throughout the shift per the following nurse's note written at 10PM: On 07/20/14 at 10:00PM, a nurse wrote that the resident was alert and up in a recliner chair. The resident refused all medications. The resident continued with involuntary jerking movements. Review of the medical record revealed no physician notification of the continued jerking movements after the administration of [MEDICATION NAME] at 2:30PM on 07/20/14. On 07/21/14 at 6:00AM, a nurse wrote that the resident was taking short naps this night. While in bed she continues with involuntary jerking movements. Review of the medical record revealed no physician notification of continued jerking movements throughout 11PM-7AM shift. On 07/21/14 at 9:00AM, a nurse wrote that the resident continued to have involuntary spasms/twitching of the right side (of her body). Review of the medical record revealed no physician notification of continued jerking movements at 9:00AM on 07/20/14. At this point in time the resident has not had any [MEDICATION NAME] since 07/18/14 at 9:00AM, three days prior. The resident has had no intervention for the jerking since 2:30PM on 07/20/14 when the [MEDICATION NAME] injection was given 15 hours prior. On 07/21/14 at 9:48AM, a nurse wrote that the resident's daughter was in and voiced her concern related to her mother's condition not improving. The daughter asked for her mother to be sent to the hospital for evaluation. The physician was notified and gave the order to transfer the resident to the hospital. Review of the Emergency Department Report revealed that resident presented in the hospital in a nonverbal state but after treatment with intravenous [MEDICATION NAME] and [MEDICATION NAME] (medications used to control [MEDICAL CONDITION]) which "nearly abated" the jerking movements. The resident was admitted to the hospital with [REDACTED]. The nursing staff's failure to notify the physician of the resident's ongoing [MEDICAL CONDITION] activity and intermittent unresponsiveness resulted in the physician not having the opportunity to assess the situation and to make changes to the plan of care earlier thereby delaying treatment.