Every finding on record at Hebrew Home of Greater Washington

Based on observations and interviews with facility staff it was determined the facility failed to ensure that a resident's environment is kept free of accident hazards. This was found to be evident for 1 (#178) of 31 resident rooms observed on the 4 [NAME] Unit during the facility's annual Medicare/Medicaid survey.Findings include:On 4/20/26 at approximately 10:00AM an observation screening was conducted on the 4 [NAME] Unit. Upon entering Resident # 178's room, a wooden mousetrap was observed on the windowsill. The resident was lying in bed at the time of the observation. At this time the surveyor requested a dual observation to be done with GNA # 14 who was in the hallway at this time. The GNA observed the mousetrap on the windowsill and stated that it should not have been in the windowsill and proceeded to remove it, and it snaped shut. The GNA stated that the mat that was on the floor next to the bed was placed there for safety. She confirmed that the resident ambulates in the room but does have confusion. The GNA stated that she would get maintenance to retrieve the mouse trap.During an interview with the DON # 2 on the same date at approximately 11:32AM she was made aware of the concerns regarding a wooden mousetrap on the resident's windowsill, she stated that it should have been placed where the resident cannot access it. She stated that education would be provided for staff.

Based on observation and interview, the facility failed to ensure that residents received care from competent, properly trained nursing staff in accordance with professional standards of practice. This deficient practice was identified for 1 (Resident #140) of 5 residents reviewed for staff competency and had the potential to place residents at risk for aspiration and other adverse outcomes.Findings include:On 4/20/26 at approximately 9:30 AM, during observation rounds, Resident #140 was observed lying in bed at approximately a 15-degree elevation while being fed by a care provider who was seated beside the bed. During the observation, the resident was heard yelling, my stomach hurts.The surveyor asked the care provider whether the resident's head should be elevated during feeding. The care provider stated, no. The resident identified the individual as his/her caregiver, stating that she feeds him/her regularly and provides care. The caregiver confirmed this information.When asked about her credentials, the care provider stated she was not a Geriatric Nursing Assistant (GNA) or Certified Nursing Assistant (CNA). She further stated she provides care for the resident until 12:00 PM, at which time another agency staff member assumes responsibility.As the surveyor exited the room, GNA #10 was asked whether she was assigned to Resident #140. GNA #10 stated, no, s/he has a private duty sitter, and confirmed that the sitter was scheduled to work until 12:00 PM.The Unit Manager (Staff #16) was informed of the observation at that time.During an interview on 4/20/26 at 11:00 AM, the Director of Nursing (DON) (Staff #2) stated that residents should only be assisted with eating by facility-trained staff. The DON further stated that she would investigate the situation.During a follow-up interview on 4/21/26, the DON stated that all Unit Managers had been in-serviced regarding the facility's policy, and that GNAs and CNAs would receive additional in-service training by the Unit Managers. The DON also stated that Resident #140's caregiver had been educated on the facility's policy.

Based on record review and interviews with staff, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices. This was found to be evident for 1 (Resident #10) out of 4 residents reviewed for hospitalizations during the annual recertification survey.The findings include:On 4/22/2026 at 9:07AM, during a review of Resident #10's electronic medical record, the Surveyor discovered that the resident was hospitalized on [DATE] due to shortness of breath. However, further review revealed the Notification of Discharge/Transfer from HHGW was not completed until 12/2/2025.On 4/22/2026 at 11:25AM, a review of the Resident Response List for discharges and transfers from November 2025, which was emailed to the Ombudsman 12/4/2025 at 9:04AM, failed to include Resident #10's transfer to the hospital on [DATE]. DON #2 confirmed that Resident #10 was not on the list. Additionally, a review of the Resident Response List for discharges and transfers from December 2025, which was emailed to the local Ombudsman on 1/6/2026 at 1:20PM, revealed that Resident #10 had an emergency transfer to the hospital on [DATE]. DON #2 confirmed that the resident was on the list. The Surveyor expressed the concern that Resident #10 was incorrectly identified as having an emergency transfer on 12/2/2025 in the December report. DON #2 confirmed these findings and the Surveyor was informed that discharges and transfers for the month are retrieved from the electronic health record's Notification of Discharge/Transfer from HHGW form type search. Nursing staff are expected to complete the Notification of Discharge/Transfer from HHGW form, along with other discharge documentation, on the same day the resident is discharged or transferred from the facility. DON #2 acknowledged that the delay in completing the form resulted in inaccurate reporting to the local Ombudsman and stated that staff education will be provided to address these concerns.

Based on observations and staff interviews, it was determined that the facility failed to ensure that the resident had reasonable accommodation of their needs. This was evident for 1 resident (Resident #2) out of 8 residents reviewed during this survey.The findings include:On 4/20/2026 at 9:53 AM, the surveyor observed Resident #2's call bell hanging on the wall out of reach. The surveyor observed that Resident #2 had restraint mittens on their hands, and the call bell was a push button.The following day, 4/21/2026 at 12:33 PM, Resident #2's call bell was observed hanging on the wall, not within reach of the resident due to immobility. The surveyor asked the unit manager, LPN #8, to come to Resident #2's room with her. LPN #8 was asked where the call bell was. LPN #8 saw the call bell hanging on the wall. LPN #8 stated that the GNA must have left it there after changing them. LPN #8 confirmed that the call bell was hanging on the wall. The surveyor then pointed out that the call bell was a push-button model and asked LPN #8 how Resident #2 was supposed to use it when their hands were wearing restraint mittens. LPN #8 stated she would have it changed to the flat call bell so the resident could use it.

Based on observation and interviews with a resident and staff, it was determined that the facility failed to ensure that a resident's call system was functioning properly. This was found to be evident for 1 resident room (room [ROOM NUMBER]) out of 36 resident rooms observed on 2 East [NAME]-Kogod Unit during the annual recertification survey.The findings include:On 4/20/2026 at 9:30AM, during an initial tour of 2 East [NAME]-Kogod, the Surveyor conducted an interview with Resident #31 in room [ROOM NUMBER]. During the interview, the Surveyor was informed that that call system in his/her room did not work because he/she pressed the call button and no one came to assist them. The resident pressed the call button. The call light above the resident's door failed to illuminate. The call station at the nurses' station failed to activate a call from room [ROOM NUMBER].During an interview with Licensed Practical Nurse (LPN #16), the Surveyor expressed the concerns that Resident #31 stated the call system in their room did not work and that after observing the resident press the call button, the call light failed to illuminate outside the resident's room and the call station at the nurses station did not activate. The Surveyor was informed that when resident presses the call button, the system should trigger a visual light illuminated outside the resident's room and another in the hallway by the nurses' station. An audible alert should be heard, as well as an activation of the resident room number from the call station to alert the staff that a resident needs assistance. Upon testing the system, LPN #16 verified it was not functioning properly and stated that they would notify maintenance immediately.On 4/20/2026 at 10:58AM, the Surveyor heard a beeping noise coming from the call station at the nurses' station on 2 East [NAME]-Kogod. Maintenance staff were observed checking the call system and subsequently informed the Surveyor that Resident #31's call system was now functioning properly.On 4/20/2026 at approximately 12:30PM, the Surveyor informed the Nursing Home Administrator (NHA) and Director of Nursing (DON) #2 of these findings with Resident #31's call system and that maintenance staff addressed the concern and made the necessary repairs.

Based on review of a Facility Reported Incident (FRI), record review, and interviews with staff, it was determined that facility failed to ensure timely notification of death to a resident's family. This was found to be evident for 1FRI (#2685784) out of 15 FRI's reviewed during the annual recertification survey.The findings include:On 4/23/2026 at 8:20AM, a review of FRI #2685784 revealed that the family member of Resident #435, who was enrolled in hospice care, expressed the concern that the resident passed away on 11/9/2025 somewhere around 7PM and the facility failed to notify the family/resident representative on 11/9/2025 until nearly 10PM. A review of Resident Change Evaluation (END OF LIFE) document completed on 11/10/2025 revealed that the resident was noted with no pulse, no respiration, no blood pressure, and no temperature at 7:35PM on 11/9/2025, while the family/resident representative notification was not recorded until 10:00PM that evening.During an interview with Director of Nursing (DON) #2 on 4/23/2026 at 8:45AM, the Surveyor expressed the concern regarding their findings in Resident # 435's Resident Change Evaluation (END OF LIFE) document. DON #2 confirmed the Surveyor's findings. DON #2 informed the Surveyor that following the facility's FRI investigation, it was determined that changes needed to be made with the hospice death notification process and that the facility has agreed to eliminate future delays in notification by ensuring families are called immediately upon confirming a resident's death.

Based on observations and interviews with facility staff, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents. This was found to be evident for 2 (Rooms #2111 and #2141) out of 36 resident rooms observed on 2 East [NAME] -Kogod Unit during the annual recertification survey. Additionally, it was determined the facility failed to ensure residents' environment was clean and well maintained. This was found to be evident for 2 (Resident # 278 and Resident # 425) of 31 resident rooms observed during the facility's annual Medicare/Medicaid survey.The findings include: On 4/20/2026 between 9:00AM and 11:00AM, during an initial tour of 2 East [NAME]-Kogod Unit, the Surveyor observed the following environmental concerns: -In room [ROOM NUMBER], structural damage to several boards of the center flooring, including soft spots, gaps between planks, edge chipping, warping, and lifting at the seams.-In room [ROOM NUMBER], a wall vent near the doorway appeared to be held in place by a peeling white duct tape like adhesive.-In room [ROOM NUMBER], there were various pink, cream, and brown colored dry patches of residue that bonded with the fibers in the green colored carpet as well as food particles were found on the carpet near the bedside table. These environmental concerns in rooms [ROOM NUMBERS] were discussed with the Nursing Home Administrator (NHA) and Director of Nursing (DON) #2 on 4/20/2026 at approximately 12:30PM. The NHA and DON #2 acknowledged the Surveyor's concerns to be reviewed with the rest of the administrative team. On 4/23/2026 at 12:35PM, a review of an email from the NHA on 4/20/2026 at 12:23PM confirmed that the facility was moving forward with the repairs for the flooring in room [ROOM NUMBER]. On 4/20/26 at approximately 9:45AM an observation screening was conducted on the 4 [NAME] Unit, and the following concerns were identified: 1. During an interview with Resident # 278 who was in an area near the nurse station, the resident reported seeing a mouse in their room earlier this morning. At this time the surveyor asked the Clinical Team Manager (CTM # 13) to accompany her to the room for a dual observation. Upon entry, the resident's trash can was full and had not been emptied. [NAME] specs were noted on the floor in the corner, and chipping was observed along the wall baseboard area. 2. An observation was made of Resident # 425's room. A large pile of clothes was noted on the floor, extending approximately midway up the wall. The resident stated this is my laundry.'' No appropriate container was in the room to put the clothes in. The Administrator was made aware of all identified concerns at approximately 12:00PM on 0420/2026.

Based on record reviews and facility staff interviews it was determined that the facility failed to ensure that the local Ombudsman was notified of the facility's resident discharges and transfers in a timely manner, at least monthly. This was found to be evident for 2 (#10, #319) out of 5 residents reviewed for hospitalizations during an annual recertification survey. The findings include: 1. On 4/22/2026 at 9:07AM, during a review of Resident #10's electronic medical record, the Surveyor discovered that the resident was hospitalized on [DATE] due to shortness of breath. On 4/22/2026 at 11:25AM, during an interview conducted with (DON) #2, the Surveyor was informed that the local Ombudsman is notified of resident discharges and transfers on a monthly basis. By the 5th of each month, an email is sent by DON #2 to the local Ombudsman notifying them of the discharges and transfers for the previous month. A review of the Resident Response List, generated on 12/4/2025 at 8:59AM for discharges and transfers for November 2025 and emailed to the Ombudsman 12/4/2025 at 9:04AM, failed to include Resident #10's transfer to the hospital on [DATE]. DON #2 confirmed that Resident #10 was not on the list. 2. On 04/22/2026 at 7:40 AM, the surveyor conducted a record review. During the record review, the surveyor could not locate any documentation indicating that the facility notified the local Ombudsman's office of Resident #319's transfer to the hospital on [DATE]. On 04/22/2026 at 8:03 AM, the surveyor interviewed the Director of Nursing (DON) #2. The surveyor asked the DON #2 if the facility notifies the local ombudsman's office of resident transfers and discharges to the hospital. The DON #2 stated that the facility notifies the local Ombudsman's office monthly, at the beginning of the month, via email of resident transfers and discharges to the hospital. Also, DON #2 indicated that she would provide the surveyor with a copy of the email that was provided to the local Ombudsman's office, which lists Resident #319's transfer to the hospital on [DATE]. On 04/22/2026 at 8:37 AM, the surveyor interviewed the DON #2. The DON #2 mentioned that the list of resident transfers and discharges to the hospital that occurred in December 2025 was emailed to the local Ombudsman's office in January 2026; however, the facility forgot to include Resident #319's transfer to hospital on that list. DON #2 also mentioned that the expectation of the facility is to provide the local Ombudsman's office with a list of all residents that were transferred or discharged to the hospital in a timely manner. On 04/22/2026 at 7:40 AM, the surveyor conducted a record review. During the record review, the surveyor could not locate any documentation indicating that the facility notified the local Ombudsman's office of Resident #319's transfer to the hospital on [DATE]. On 04/22/2026 at 8:03 AM, the surveyor interviewed (DON) #2. The surveyor asked DON # 2 if the facility notifies the local Ombudsman's office of resident transfers and discharges to the hospital. DON # 2 stated that the facility notifies the local Ombudsman's office monthly, at the beginning of the month, via email of resident transfers and discharges to the hospital. DON #2 indicated that she would provide the surveyor with a copy of the email that was provided to the local Ombudsman's office, which lists Resident #319's transfer to the hospital on [DATE]. On 04/22/2026 at 8:37 AM, the surveyor interviewed DON # 2. DON #2 mentioned that the list of resident transfers and discharges to the hospital that occurred in December 2025 was emailed to the local Ombudsman's office in January 2026; however, the facility forgot to include Resident #319's transfer to hospital on that list. DON #2 also mentioned that the expectation of the facility is to provide the local Ombudsman's office with a list of all residents that were transferred or discharged to the hospital.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice by not following the physician's order for applying a hand mitt restraint. This deficient practice was identified for 1 (#2) of 8 residents reviewed for physician orders.Findings include:On 4/20/2026 at 9:53 AM, the surveyor observed Resident #2 in bed wearing hand mitt restraints on both hands.On 4/21/2026 at 10:35 AM, the surveyor observed Resident #2 wearing only one mitt on the left hand. The surveyor immediately interviewed the Unit Manager, LPN #8, regarding the prior observation. LPN #8 stated that the mitt had been removed from the resident's right hand because the physician's order specified application to the left hand only.On 4/21/2026 at 12:59 PM, the surveyor reviewed the medical record for Resident #2. Review of the physician's orders confirmed the following directive: Apply hand mitt to left hand to prevent removal of G-tube and/or self-injury. Monitor and document every shift for safety, skin integrity, and continued need. Remove at least once per shift for skin assessment and range of motion. Attempt daily trial removal when condition permits.The order further required ongoing evaluation and documentation of the restraint's continued need, including assessment of behavior, safety risk, skin integrity, and alternative interventions weekly.The observation on 4/20/2026 revealed that Resident #2 was wearing mitt restraints on both hands, which contradicted the physician's order specifying use on the left hand only.This failure to follow the physician's order placed the resident at risk for unnecessary restraint use and did not ensure care and treatment in accordance with professional standards of practice.

Based on observation, interview and record review, it was determined that the facility failed to make reasonable effort to substitute alternative meal through observations of meals not being eaten. This was evident for 1 (Resident #193) out of 1 residents reviewed for food/drink during the annual survey.The findings include: An observation regarding Resident #193 that occurred on 04/20/2026. At 1:25 PM, the resident declined their lunch tray, informing Geriatric Nursing Assistant (GNA) #15 that the food was too hard and that they do not eat fish. The resident stated an egg salad sandwich would be nice. Despite this direct request, GNA #15 took no action to contact the kitchen for an alternative meal.At 1:31 PM, this surveyor alerted the Unit Manager #7, who visited the room and heard the resident repeat the request for egg salad sandwich. The Unit Manager noted that GNA #15 omitted a request for the resident, who was hungry. The kitchen was subsequently notified to prepare an alternative tray; later the resident was observed eating and finishing an egg salad sandwich.Conducting a follow-up interview with Resident #193. During our conversation, the resident was able to make needs known and stated they were unaware that alternative trays could be requested. A record review conducted on 04/21/2026 at 08:33 AM for Resident #193 revealed the following information:- Medical History: The resident was admitted in 2022 with a history of stroke, unspecified dementia without behavioral disturbance, and anxiety disorder.- Assessments: The BIMS score from the previous year's quarterly assessment was 12.- Dietary and Nutrition: A diet order dated 11/12/2025 included a daily snack at 2 PM, and nutrition notes indicate the resident was on weight monitoring.- Meal Documentation: The kitchen's lunch meal ticket from 04/20/2026 listed an alternative for egg salad but failed to specify the no fish restriction.BIMS (Brief Interview for Mental Status) It is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility. BIMS Score: 0-7 points as Severely Impaired Cognition, 8-12 points as Moderately Impaired Cognition and 13-15 points as Intact Cognition.During an interview with Unit Manager #7 on 04/21/2026 at 11:03 AM, we discussed findings regarding practice concerns at the facility staff. Specifically, it was noted that Resident #193 has lived in the facility for over four years but remains unaware of available alternative trays. Additionally, staff have not made any effort to offer these alternatives even with being prompted. Final interview with the Administrator, 4/23/26 at 12:30 PM, reviewing the concern as a deficiency practice. He stated the facility staff will be re-educated.

Based on observations, interviews, and record reviews, the facility failed to keep the resident free from verbal and mental abuse as evidence by a social worker demonstrating verbal and non-verbal aggressive behavior toward the resident which caused and had the potential to cause the resident to experience humiliation, intimidation, shame, agitation, and/or degradation and did not promote an environment to enhance the resident's dignity. An observation of Resident 17 (R17) on 10/17/25 at 9:40 a.m., revealed a well-groomed person lying in bed who had just finished eating lunch independently. R17 was pleasant and engaging with good recollection of the incident. The room was clean, uncluttered and odor free. An interview with R17 on 10/17/25 at 9:40 a.m., revealed he/she recalled the incident with the Social Worker (SW24) in detail. R17 stated SW24, talked a lot and always had a negative connotation or attitude and that was typical of SW24. R17 stated during the incident, SW24 Jumped up and shouted and screamed, which made R17 feel disrespected and degraded. R17 stated that he/she has not worked with SW24 since the incident. An interview on 10/16/25 at 2:15 p.m. with the Director of Nursing (DON), revealed the witness to the incident was a support planner from a community integration services company who was working with R17 regarding placement outside of the facility. The DON stated that the support planner did not report the incident and was later educated by the Director of Social Work regarding professionalism and abuse. Several attempts were made to contact the support planner. A voicemail and email were sent without return correspondence. In an interview with the facility's human resources representative (HR23) on 10/17/25 at 11:30 a.m., he/she stated SW24 was terminated due to a pattern of behavioral infractions, including the incident with R17, adding that SW24 had violated the facility's policies regarding communication style and code of conduct. A review of R17's medical record Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident had intact cognition. Further review of the resident's record revealed no diagnoses of, medications or treatment for dementia, impaired cognition, mood or behavioral disturbances. A review of R17's progress notes between 6/15/25 and 7/16/25 did not reveal any documentation of the incident being investigated.A review of the facility investigation for revealed a thorough and appropriate investigation with timely reporting to the appropriate entities although it did not verify abuse. Instead, the facility verified Quality of Care/Treatment and Administration/Personnel. The facility investigation showed R17 reported the incident to the Clinical Team Manager (CTM) and Supervisor on 6/25/25, telling them that the incident had occurred on 6/20/25 in SW24's office with the community planner present. SW24 was immediately removed from the schedule pending investigation. During the investigation on 7/2/25, R17 stated to the investigator that he/she felt like SW24 was going to come across the desk and hit her. Further review of the investigative conclusion documented, .the behavior of SW24 was inappropriate, unprofessional, and humiliating toward [R17], and SW24 also stood up in front of [R17] in an intimidating way with an inappropriate tone, which was considered emotional abuse.behavior was inappropriate and threatening toward [R17]. A review of the support planner's statement revealed, . [social worker] spoke at a passionate level that could be understood as yelling by [R17] .I do not think he/she yelled at him/her, but I will say that he/she did reprimand him/her for making the statement.[SW] was a little too passionate.I could tell R17 was not happy with the tone. I would describe it as being called into the principles [sic] office and being chastised for your behavior.o The facility's policy titled, Organizational Policy on Resident Abuse for HHGW dated 03/1998 with last revision and approval date of 01/2025 was reviewed without concerns. Within Section I. Policy Statement, it commands, Any associate, contracted provider, or volunteer, observing, knowing of, suspecting, or receiving any allegation of abuse, neglect or exploitation shall immediately report any of the above circumstances to their immediate supervisor, the Clinical Team Manager for the unit (Hebrew Home of Greater [NAME]), their shift supervisor, or Executive Director. Reporting must be immediate, without delay. Further, the policy defines abuse as, the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. 3. Psychological or verbal abuse: Mistreatment that affects a person's emotional or mental health or wellbeing, including but not limited to: intimidation, threats of punishment or harm, harassment, humiliation, insults, belittlement, or isolation. The use of oral, written or gestured language that disparages or demeans residents or their families, regardless of their age, ability to comprehend, or disability. Examples include, but are not limited to: threats of harm; saying things to frighten a resident.The facility implemented corrective action plans to include: The termination of SW24, education/in-servicing provided to all staff on abuse and communication which was reviewed without concerns, and education provided to outside coordination of care workers on abuse and reporting and accompanying policy requiring the same. The facility provided a copy of email correspondence between the Director of Social Work and the support planner from the community integration service company. The email was dated 7/3/25 and stated, in part, if you are vising any residents in our facility and you see anything that could be misconstrued as hostile, negative, abusive, or unprofessional by our staff toward any resident, we ask that you inform someone of what you saw, no matter how miniscule or flagrant it may be. We at HHGW want to insure [sic] the best overall experience and safety to our residents. The email was acknowledged and signed by the support planner on 7/7/25.The facility verified the allegations of Quality of Care/Treatment and Administration/Personnel; however, this surveyor's investigation will substantiate a past noncompliance finding of the deficient practice of abuse (mental/verbal) as evidenced by a social worker demonstrating verbal and non-verbal aggressive behavior toward the resident which caused and had the potential to cause the resident to experience humiliation, intimidation, shame, agitation, and/or degradation and did not promote an environment to enhance the resident's dignity.

Based on observations, interviews, and record revies, the facility failed to provide adequate supervision to Resident 20 utilizing an elopement prevention device as evidenced by R20's elopement from the monitored area and the building of residence for approximately 2 hours. An observation of Resident 20 (R20) on 10/14/25 at 1:20 p.m. revealed a well-groomed person sitting on the side of the bed eating lunch. R20 also had water and juice within reach and, he/she did not require assistance with eating. There was no observable WanderGuard in place. The room was clean, cluttered and odor free. An observation of R20's unit 10/14/25 at 1:20 p.m., unit revealed there were cameras pointing toward the exit door and one in the middle, pointing toward the nursing station. The elopement monitoring system testing was observed and appeared to be working properly. An interview with R20 on 10/14/25 at 1:20 p.m. revealed he/she did not have a WanderGuard device in place. When asked about leaving the building, R20 stated, I can't leave the building, however, he/she could not explain the reason he/she could not leave the building. R20 stated he/she had salmon and rice for lunch. R20 stated he/she felt safe. In an interview on 10/16/25 at 2:15 p.m. with the Administrator and the Director of Nursing (DON), they simultaneously recounted the events that took place during R20's elopement event as follows: R20 was able to call and enter the elevator due to a glitch in the WanderGuard monitoring system, allowing the elevator doors to close and any floor to be accessed. At the time, the system was being tested weekly. The alarm sounded at approximately 5:00 p.m., and staff immediately pursued R20, and a building search was initiated by several staff. Staff who followed R20 exited the elevator on the ground/first floor; however, R20 had gone to the lower/basement level to exit the elevator. During the facility investigation, R20 admitted his/her actions were made with purposeful intent in order to leave undetected. The resident exited by a loading dock door and was not discovered by the cook from Revitz house in the black van until approximately 6:40 p.m. The facility was unable to verify when R20 entered the black van. The cook and another Revitz staff member assisted R20 into the black sedan. The second Revitz House staff member initially drove R20 to Ring House and then eventually back to the [NAME] building where R20 was assisted back to unit 2 North. When asked the definition of elopement, DON stated, Elopement is someone leaving unit without following protocol, without signing out. By definition that was elopement. Staff did not know where he was. The administrator agreed, adding it's a gray area. When asked the reason the facility did not verify the self-report, DON stated, because we found that this man did not have the intent to elope, and because staff saw him get on the elevator. R20's sibling had taken the resident's cellular telephone, and it was R20's intent to go to Verizon to obtain another phone. He did know the procedure to leave and did not follow it. When asked the reason for the WanderGuard placement, the DON responded, .he did not show any signs of leaving but it was the sibling who informed the staff that R20 would leave. When asked about the operation of the WanderGuard system, the administrator stated when the alarm sounded, it should have shut down the means of egress. He/she further explained the elevator doors would open, but they should not close, explaining that was the glitch in the system. The administrator stated that the system is currently working properly with each test, adding the doors will open but they will not close when the alarm sounds. There was also no transmitter on the basement door nor on the loading dock door. The administrator stated that the system is now physically tested to ensure proper functioning three (3) times daily, adding they have begun the process to acquire a new system for both buildings so that when an alarm sounds, the buildings will shut down and disallow anyone exiting. During the facility investigation, R20 was able to take the investigator step-by-step, recounting the entire event, stating the intention was to go to the Verizon store. When asked the reason R20 was not placed within a locked dementia unit, the DON stated R20 did not yet require that level of care, adding that resident's often transition from one unit to the other as their level of needed care increases. A review of R20's orders revealed no evidence of an order for a WanderGuard or other location monitoring device. A review of R20's medical record revealed no evidence of a consent for a WanderGuard or similar location monitoring device. A review of R20's medical record Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicating the resident had intact cognition. Further review revealed no wandering behavior was present and no wander/elopement alarm was not in use. A review of R20's elopement risk assessments was made revealing three assessments completed on 3/21/25, 4/2/25, and 4/15/25. The assessments dated 3/21/25 and 4/2/25 showed scores of 1, indicating a low risk for elopement. The assessment dated [DATE] showed a score of 3, indicating a moderate risk for elopement. A review of R20's record reveals he/she was receiving physical and occupational therapies throughout the month of April 2025 and had a history of recurrent falls at home on and prior to 3/14/25. He/she required partial assistance for transfers and used a cane and/or a wheelchair for locomotion. A review of R20's care plan dated 3/21/25 and revised on 4/17/25 revealed, [R20] may be at risk for and/or experiencing a decline in psychosocial well-being/perceived quality of life due to change in environment, mobility decline/ deficit. 4/17/2025 room changed from 294 2n to rm407 4w. A review of R20's care plan dated 4/2/25 (prior to the elopement date of 4/13/25) and revised on 4/18/25 stating, [R20] has actual/potential for elopement related to a high elopement risk assessment score, to the resident's recent exit from the facility without informing staff. All interventions on this care plan were initiated between 4/14/25 and 4/16/25 except one. The one exception was initiated on 4/2/25, and it read, Wander guard transmitter to monitor for unsafe wandering. Check for functioning three times a week. A review of R20's Treatment Administration Record (TAR) revealed a schedule for the month of April 2025 for, Wander Guard to Rt leg due to risk of elopement. Every evening shift every Wed The nurse or GNA must take the resident to the elevator and attempt to get on to the elevator. If no sound or alert before or after entry into the elevator, please contact the supervisor and the front desk for a new transmitter, with a start date of 4/3/25 at 3:00 p.m. and no discontinuation date. There were check marks (indicating administered) and staff initials on 4/9/25 and 4/16/25. Two boxes, 4/22/25 and 4/30/25 were blank. All remaining boxes for each day of the month of April 2025 contained the letter x, indicating the task was no required. A review of R20's TAR revealed a schedule for the month of April 2025 for, Wander Guard to Rt leg due to risk of elopement. Every shift check strap and transmitter for placement. Assess, document, and follow-up on related skin issues identified, with a start date of 4/4/25 at 6:00 p.m. and no discontinuation date. The boxes dated 4/1/25 for both shifts contained the letter x, indicating the task was no required. The boxes dated 4/21/25 through 4/30/25 were blank. There were check marks (indicating administered) and staff initials for both shifts in the boxes dated 4/3/25 through 4/20/25 with the exception of a blank box for the morning shift on 4/15/25. A review of R20's TAR revealed a schedule for the month of April 2025 for, Wander Guard to Rt leg due to risk of elopement. In the evening every Mon, Fri Nurse to remind the shift supervisor to check the resident's wander guard using the code alert sensor for functioning. Supervisor to report issues identified to the front desk for replacement with a start date of 4/4/25 at 6:00 p.m. and no discontinuation date. The boxes dated 4/4/25, 4/7/25, 4/11/25, 4/14/25, and 4/18/25 contained check marks (indicating administered) and staff initials. The boxes dated 4/21/25, 4/25/25, and 4/28/25 were blank. The remaining boxes contained the letter x, indicating the task was no required. A review of R20's Social Work Behavioral Health assessment dated [DATE] revealed the resident to be his/her own decision-maker, a review of three most recent BIMS scores of 15/15 each, with baseline dementia, alert and oriented x2, and medication for dementia. The referral was made on 4/10/25 and completed on 4/21/25, and the referral was made due to inappropriate sexual behavior. There was no indication of exit-seeking behavior outlined in the assessment. A review of R20's nursing progress noted dated 4/14/25 at 6:30 a.m., noted the resident was received eating in his/her room at the beginning of the shift and thereafter through the shift pt remain stable calm in room watching TV, and there was no attempt to leave the room noted. A review of R20's social work progress notes dated 4/2/25, 4/6/25, 4/10/25, and 4/11/25, revealed, Behavioral/Mood concerns noted include(s): Sadness Wandering, Patient is constantly asking to go home. Social Work note dated 4/9/25, noted, Worsening Behaviors: Since admitted , see [sic] more confused at times, restless, wandering, strange statements. Check labs. Social Work noted dated 4/14/25, noted, .Yesterday however reports pt had left unit and could not be found in building for ~30 mins. Eventually [R20] was brought back to building. R20 recounted of the elopement to the Social Worker, although R20's recollection does not fully match the review of the events. Notably, R20 stated he/she was able to get to the Verizon store before his/her return, but witnesses and facility documentation do not corroborate that R20 ever left facility proper. R20 recounts a woman returned him to the building; however, witnesses and facility documentation indicate it was a man who returned him to the building. Further SW documentation revealed a conversation with R20's sibling who reports a long history of confusion to include, .a tendency to become confused.resident is very smart and can make stories sound true.has had a couple of delusional episodes here, calling sibling and stating that everyone is in the parking lot under their car hoods fixing their cars. also reports, that while resident was at home, resident called.a bad storm had knocked down a tree which knocked out the windows and flooding. Upon investigation by the sibling, these events did not happen, i.e. there was no storm, power outage, or building damage. The sibling stated, .resident, in many instances, can seem cognitively ok, but that [R20] is not.has periods where he/she is lucid and in the same breath can be fully impaired. The care team along with the DON was updated with this information. Additionally, the social worker noted that a room transfer was initiated but later cancelled due to reevaluation of need for a secured unit. A social work progress note made by the Director of Social work dated 4/14/25, revealed a Brief Cognitive Assessment Tool (BCAT) was conducted with a score of 14, suggestive of Dementia or Severe Cognitive Impairment. A review of the facility investigation for revealed a thorough and appropriate investigation with timely reporting to the appropriate entities although it did not paint a clear and concise recapitulation. Upon review of the facility investigation, a concern of potential Immediate Jeopardy arose which was believed to have had the potential to have caused serious injury, harm, impairment, or death to a resident because of an elopement for approximately two (2) hours. A meeting was held with the Maryland Department of Health (MDH) on 10/16/2025 at 2:30 p.m. to discuss the findings of a potential Immediate Jeopardy. The MDH stated they failed to see the harm or potential harm caused by R20's elopement, and they determined this did not meet the requirements of Immediate Jeopardy. The investigation showed R20 got onto the elevator at 5:00 p.m., and was not located by the Revitz House cook staff until approximately 6:40 p.m. When the cook discovered R20 sitting in the driver's seat of the black van, he/she went back into the Revitz building to request help from another staff member. The cook stated R20 told him/her that he/she was cold and needed help. When the alarm sounded, the resident was followed by staff who exited on the first floor and informed/inquired to the front desk receptionist who had not seen the resident. The staff who followed assumed that because the resident did not exit via the front door that, he/she must have been in one of the units therefore all units, dining rooms, and bathrooms were searched withing the [NAME] building. The Missing Person Alert was also not activated for the same reason.The facility's elopement policy titled, Resident Elopment-Hebrew Home of Greater [NAME], dated 09/1998 with last revision and approval date of 5/2025 was reviewed without concerns. It defines elopement as, refers to when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. The facility implemented corrective action plans to include: Revision of the resident elopement policy and procedures, in-servicing staff on Missing Resident Response Protocol & Prevention, an increase WanderGuard testing to three (3) times daily, an updated care plan for R20, and updated treatment administration record to monitor R20's behavior.The facility did not verify the allegation of Quality of Care/Treatment; however, this surveyor's investigation will substantiate a past noncompliance finding of the deficient practice of residents receiving adequate supervision and assistance devices to prevent accidents as evidenced by R20's elopement from the monitored area and the building of residence for approximately 2 hours.

Based on review of the facility's pest activity logs and interviews, the facility failed to maintain an effective pest control program. This was evident for 1 of 2 buildings reviewed during the recertification/complaint survey. The findings include: During investigation of multiple complaints including August and October 2024 regarding mice in the facility's [NAME] building from residents' responsible parties the surveyor requested on 2/4/25 the facility's pest control logs from September 2024 through February 4th, 2025. Interview with Staff #23 (Vice President of Building Services) on 2/4/25 at 10:45 AM, Staff #23 states the facility consists of 2 buildings and each building maintains a pest control log at the front desk for the pest control company to address any concerns. Staff #23 stated the pest control company comes to the facility 3 times a week. Review of the Pest Activity Log on 2/4/25 for the [NAME] Building revealed the following entries in patient care areas: 9/2/24 room [ROOM NUMBER] mouse droppings in room, room [ROOM NUMBER] mouse droppings in room 9/4/24 room [ROOM NUMBER]-226 mouse sighting, 4th floor dining room mouse sighting 9/5/24 room [ROOM NUMBER] mice sighting, room [ROOM NUMBER] mice in hallway ran under door to enter room 9/6/24 room [ROOM NUMBER] mice in resident room, so scared might jump on bed 9/11/24 room [ROOM NUMBER] dead mouse in trap 9/12/24 room [ROOM NUMBER] resident reported a mouse jumped on bed yesterday, room [ROOM NUMBER] mice running 9/13/24 room [ROOM NUMBER] patient saw a mouse 9/15/24 5th floor tv room mouse sighting, room [ROOM NUMBER] mice sighting by resident, room [ROOM NUMBER] mouse sighting 9/16/24 5th floor tv room mouse running around, 3rd floor dining room mouse running around, room [ROOM NUMBER] mice sighting, room [ROOM NUMBER] mice sighting 9/17/24 room [ROOM NUMBER] mice sighting 9/20/24 room [ROOM NUMBER] mouse running around bedroom, room [ROOM NUMBER] mice running in and out of closet and around bedroom 9/23/24 room [ROOM NUMBER] 2 rats running by room, room [ROOM NUMBER] mouse in room for months, room [ROOM NUMBER] mouse observed in room 9/24/24 room [ROOM NUMBER] mouse running in room 9/25/24 room [ROOM NUMBER] mice running around room 9/27/24 room [ROOM NUMBER] mice in room everynight 9/30/24 room [ROOM NUMBER] mouse seen by resident, 5th floor tv room mice sighted 10/8/24 room [ROOM NUMBER] mice seen in room, room [ROOM NUMBER] mice seen in room, room [ROOM NUMBER] mouse droppings 10/9/24 room [ROOM NUMBER] mice in room, room [ROOM NUMBER] mice in room, 5N/5W hallways mice sightings, 5W tv room mice sightings 10/10/24 room [ROOM NUMBER] live mouse in room, room [ROOM NUMBER] mouse running around room, room [ROOM NUMBER] resident saw mouse in room, room [ROOM NUMBER] mice, 4th floor dining room mouse sighting 10/11/24 room [ROOM NUMBER] last night fat mouse bigger than a mouse smaller than a rat. It was in room running around 10/12/24 room [ROOM NUMBER] live mice running across the room 10/15/24 Rooms 264, 393 and 287 mouse sighted in room 10/17/24 room [ROOM NUMBER] one mouse seen in room, room [ROOM NUMBER] mice in room, room [ROOM NUMBER] mouse running in room, room [ROOM NUMBER] mouse in room 10/18/24 room [ROOM NUMBER] resident reported a mouse in room last night, room [ROOM NUMBER] mouse in room 10/20/24 room [ROOM NUMBER] mouse sighted in room, 4 North tv room mice observed, 4 North nursing station mice observed 10/21/24 room [ROOM NUMBER] mice sighting, 3 North nursing station mice sighting 10/22/24 room [ROOM NUMBER] mouse sighting, mouse sighting 10/23/24 room [ROOM NUMBER] mouse ran from hallway into room, room [ROOM NUMBER] mouse sighting 10/24/24 room [ROOM NUMBER] 3 mice seen, 3 North food prep mice seen by visitor running around, room [ROOM NUMBER]A mouse running 10/25/24 room [ROOM NUMBER] and 279 mouse, 3 North food prep mice running, 4W/3N tv room multiple mice running around, Rooms 370, 368 and 366 mice, 2 N 3 mice spotted crossing hallway, 3 N mouse running in hallway into one of the rooms 10/28/24 Rooms 588, 281, 368 mouse sighted in room 10/29/24 Rooms 391, 389, 266, 387 mouse sighted in room 10/30/24 Rooms 277, 258 mouse sighted in room, room [ROOM NUMBER] mice running around room, keeps running on bed, room [ROOM NUMBER], 464 mice running around room 10/31/24 Rooms 275, 271, 270, 285, 281 mice sighted in room 11/1/24 room [ROOM NUMBER], 410, 556 mouse running around the room, 5W tv room mice, room [ROOM NUMBER] mouse droppings 11/3/24 room [ROOM NUMBER] dead mouse in closet 11/4/24 Rooms 391, 387, 381, 445, 410, 398, 266 mice seen in room 11/5/24 Rooms 554, 560, 566 mouse sighted in room, 5 N tv room mouse seen 11/6/24 Rooms 596, 266 mouse sighted in room 11/7/24 Rooms 445B, 568, 481 mouse sighted in room, Hallway 571-579 mice running 11/8/24 room [ROOM NUMBER] mice running in and out of room, 3N/5W tv area mouse running 11/9/24 room [ROOM NUMBER] mouse in room 11/11/24 4N tv room mice sighted 11/12/24 room [ROOM NUMBER] mice running around room 11/13/24 Rooms 286, 287 mouse sighted in room 11/14/24 room [ROOM NUMBER] family complained continue to see mice in room especially at night, 4N tv room [ROOM NUMBER] mice 11/15/24 4N living area mice 11/18/24 room [ROOM NUMBER] mice sighted in room 11/19/24 Rooms 202, 203, 201 mouse sighted in room 11/22/24 Rooms 558, 283 mouse sighted 11/25/24 Rooms 406, 407 mouse sighed in room 12/3/24 room [ROOM NUMBER] mouse sighted in hallway, room [ROOM NUMBER] droppings in room 12/4/24 3 N tv room mouse sighted 12/6/24 room [ROOM NUMBER] mouse observed 12/9/24 room [ROOM NUMBER] 2 mice moving around room 12/13/24 room [ROOM NUMBER] mice running in and out of bedroom 12/14/24 room [ROOM NUMBER] live mouse seen in room, room [ROOM NUMBER] mouse coming into room 12/15/24 Rooms 516, 526, 394, 395 mouse sighted in room 12/17/24 room [ROOM NUMBER] dead mouse in trap 12/18/24 3 N tv room mice seen, 3 N nurses station mice seen, room [ROOM NUMBER] mice seen 12/19/24 3 N tv room [ROOM NUMBER] mice running across room and nursing station 12/25/24 room [ROOM NUMBER] mouse observed in room 12/26/24 4 N tv room mouse running under A/C 12/27/24 room [ROOM NUMBER] mouse seen, 3 N nursing station mouse seen 12/30/24 Rooms 516, 520, 524 mouse sighted in room 1/2/25 4 W tv room dead mouse on trap 1/5/25 room [ROOM NUMBER] dead mouse in room, room [ROOM NUMBER] dead mice on glue board, 1st floor nursing station dead mouse on snap trap 1/19/25 Rooms 383, 373, 397, 394, 388 mouse sighted in room 1/22/25 Mouse in hallway outside room [ROOM NUMBER] 1/24/25 5 N shower room Resident saw a mouse in the shower room, room [ROOM NUMBER] Resident saw a mouse in hallway by room 1/30/25 room [ROOM NUMBER] Patient reported seeing a mouse in room 2/2/25 room [ROOM NUMBER] mouse caught on glue board 2/3/25 3 N tv room mouse sighted in room, 3 N nurses station mouse sighted, room [ROOM NUMBER] mouse sighted in room The Surveyor then conducted the following interviews on 2/4/25 and 2/7/25: Interview with the resident in room [ROOM NUMBER] on 2/4/25 at 1:54 PM, the resident stated he/she saw a mouse in his/her room last week. Interview with the resident in room [ROOM NUMBER] on 2/4/25 at 1:55 PM, the resident stated he/she sees a mouse every day that runs from the closet to under the dresser in his/her room. Interview with the resident in room [ROOM NUMBER] on 2/4/25 at 2:04 PM, the resident stated he/she has a mouse under his/her chair every night. Interview on 2/4/25 at 2:05 PM with GNA #45 (geriatric nursing assistant), she stated she saw a mouse last week in the resident hallway and told the housekeeper. Interview with the resident in room [ROOM NUMBER] on 2/4/25 at 2:10 PM, the resident stated he/she saw a mouse about 2 weeks ago and told the staff. Interview with the resident in room [ROOM NUMBER] on 2/7/25 at 8:50 AM, the resident stated saw a mouse a couple days ago in his/her room. Interview with the resident in room [ROOM NUMBER] on 2/7/25 at 8:57 AM, the resident stated he/she saw a mouse last week in his/her room. Interview with the resident in room [ROOM NUMBER] on 2/7/25 at 9:00 AM, the resident stated he/she saw a mouse 2 weeks ago that ran from under the heater. Interview with the resident in room [ROOM NUMBER] on 2/7/25 at 9:03 AM, the resident stated he/she saw a mouse in the hallway last night. Interview with the resident in room [ROOM NUMBER] on 2/7/25 at 9:05 AM, the resident stated he/she sees a mouse in his/her room every night. Interview with the resident in room [ROOM NUMBER] on 2/7/25 at 10:36 AM, he/she saw a mouse in his/her room a couple of days ago. Interview with the resident in room [ROOM NUMBER] on 2/7/25 at 10:39 AM, the resident stated he/she saw a mouse in his/her room last night. Interview with the resident in room [ROOM NUMBER] on 2/7/25 at 10:41 AM, the resident stated he/she saw a mouse a week ago at the doorway to room. Interview with the resident in room [ROOM NUMBER] on 2/7/25 at 10:43 AM, the resident stated he/she saw a mouse run across the hallway through the shower room last week. The findings were reviewed with the Administrator on 2/7/25 at 12:30 PM.

Based on review of facility reported incidents with documentation and interview, it was determined the facility failed to report allegations of abuse, neglect, and injuries of unknown origin within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 18 (#631, #647, #646, #627, #641, #637, #621, #5, #620, #250, #94, #229, #157, #96, #278, #264, #77, and #48) residents of 60 facility reported incidents reviewed during an annual and complaint survey. The findings include: 1) On 1/27/25 at 10:12 AM a review of facility reported incident MD00188273 revealed Resident #631 alleged that he/she was raped 5 nights prior by multiple guys. On 1/26/23 at 16:25 (4:25 PM) the daughter informed facility staff. The facility's investigation included an email confirmation as to when the initial report was sent to OHCQ. Review of the email confirmation documented the email was sent to OHCQ on 1/26/23 at 8:55 PM. This was not within 2 hours of the allegation. On 1/28/25 at 2:15 PM the facility reported incident was reviewed with the DON #1. The surveyor showed the DON #1 the initial email confirmation which documented the report was sent at 8:55 PM and was not within 2 hours of being informed. The DON #1 stated, oh it did not get sent within 2 hours. I will have to check into that. On 1/29/25 at 8:18 AM the DON #1 brought the abuse policy to the surveyor and stated they did not have to report within 2 hours unless there was an injury. The surveyor informed the DON #1 of the regulation. The DON #1 stated understanding, and they would have to change the way they report. 2) On 1/27/25 at 1:05 PM a review of facility reported incident MD00204909 revealed Resident #647 was found with skin discoloration/bruise to the right hip on 4/21/24 at 8:15 PM. The assigned geriatric nursing assistant (GNA) notified the charge nurse. The charge nurse notified the physician, the responsible party and the shift supervisor. The shift supervisor failed to immediately notify nursing administration or the facility's administrator. Nursing administration was not notified until 4/22/24 at 8:25 AM. Review of the email confirmation for the facility report to OHCQ documented that the initial report was not sent until 4/22/24 at 10:59 AM which was not within 2 hours of finding the injury of unknown origin. On 1/28/25 at 2:10 PM an interview was conducted with the Director of Nursing (DON #1) who confirmed that the incident was not reported within 2 hours. 3) On 1/27/25 at 2:01 PM a review of facility reported incident MD00201444 documented that on 1/9/24 at 11:48 AM staff from a radiology company reported to the facility that Resident #646 had rib fractures that were found during the completion of a CT scan. Review of the facility's investigation failed to produce an email confirmation as to when the initial self-report was sent to OHCQ. Review of the facility's timeline documented that the initial self-report was not sent to OHCQ until 1/10/24 at 13:10 (1:10 PM). This was not within 2 hours of becoming aware of the fractures. On 2/4/25 at 7:47 AM an interview was conducted with the DON #1. The DON #1 stated they talked about it as a team first before sending it to OHCQ. She said they are changing their process to report first before they discuss as a team. 4) On 1/28/25 at 8:42 AM a review of facility reported incident MD00193732 revealed Resident #627 alleged that he/she had been assaulted by the GNAs on 6/25/23 at 6:00 AM. The investigation documented that the nursing shift supervisor was notified. The investigation documented that during the shift staff continued to monitor, encourage, and re-approach the resident several times to provide care but the resident was combative, refused care, bladder scanning, and fingerstick checks. Resident #627 continued to allege that he/she was still being abused, and that staff were holding the resident captive. The facility's investigation documented that the DON #1 and Assistant Director of Nursing (ADON) were not notified until 14:00 (2 PM). Review of the initial report email confirmation revealed the self-report was emailed to OHCQ on 6/25/23 at 4:13 PM. It was not reported within 2 hours of the resident reporting the alleged abuse. On 1/28/25 at 10:43 AM an interview was conducted with the DON #1 and the Clinical Risk Manager. The email confirmation was reviewed, and they acknowledged that the report was not submitted within 2 hours. On 1/29/25 at 8:18 AM the DON #1 brought the abuse policy and stated they did not have to report within 2 hours unless there was an injury. The surveyor was informed of the regulation. The DON #1 stated understanding and that they would have to change the way they report. 5) On 1/28/25 at 12:53 PM a review of facility reported incident MD00166270 was conducted and revealed on 4/16/21 Resident #641 was noted with swelling and discoloration to the left hand fourth finger with a complaint of pain. An x-ray was performed and revealed an acute fourth proximal phalanx fracture. The facility became aware of the x-ray result at 22:22 (10:22 PM). Review of the facility's investigation revealed an email confirmation that the initial self-report was sent to OHCQ on 4/16/21 at 11:00 PM. Further review of the facility's investigation revealed that on 4/16/21, GNA #41 documented, I gave resident shower in the morning. Did not notice any discoloration to finger on hand. During lunch I noticed a slight discoloration on [his/her] 4th finger on the left hand. I told another GNA. Meant to tell the charge nurse but forgot to because I was busy during the lunch period and after lunch. GNA #41 failed to immediately report the injury of unknown origin immediately to the charge nurse and/or nursing administration. On 2/4/25 at 2:26 PM the investigation was discussed with the DON #1 who confirmed the findings. 6) On 1/29/25 at 2:33 PM a review of facility reported incident MD00209039 was conducted and revealed Resident #637 alleged that a GNA who had taken care of the resident that morning was mean and rough. It was documented that Resident #637 stated, she was mean and rough to the point of being abusive. Review of the facility's investigation revealed the allegation was reported to staff on 8/21/24 at 15:57 PM (3:57 PM). The email confirmation to OHCQ documented that the initial report was sent on 8/22/24 at 11:57 AM, which was not within 2 hours of being reported to staff. Review of the 5-day report also documented that the initial self-report was not sent to OHCQ until 8/22/24 at 12:45 PM. On 2/3/25 at 8:17 AM an interview was conducted with the DON #1. The DON #1 confirmed that the report was not sent within 2 hours because the GNA had already left for the day, and they waited until the next day to send the report to OHCQ. The DON #1 stated, at the time since there were no injuries we did not realize we had to report within 2 hours. 7) On 2/3/25 at 8:00 AM a review of facility reported incident MD00208804 was conducted and revealed on 8/15/24 Resident #621 was noted to be grimacing when the right arm was lifted during morning care. An x-ray was done and revealed an acute fracture of the humerus. Review of the facility's investigation revealed the staff learned of the fracture on 8/15/24 at 4:37 PM. Review of the initial self-report failed to reveal an email confirmation as to when the initial self-report was submitted to OHCQ. On 2/4/25 at 9:47 AM the DON #1 was interviewed and stated, we were not getting a receipt. We were not checking the box to get a copy with the time the report was submitted. We will have to educate whoever is submitting the reports. 8) On 2/3/25 at 11:20 AM a review of facility reported incident MD00194070 was conducted and revealed Resident #5 alleged to his/her son that Resident #5 had been hit on the back and arm by staff during care. Review of the facility's investigation revealed the allegation was reported to staff on 7/4/23 at 16:00 (4 PM). The email confirmation to OHCQ documented that the initial report was sent in on 7/5/23 at 4:40 PM, which was not within 2 hours of being reported to staff. On 2/4/25 at 7:53 AM an interview was conducted with the DON who stated they talked about it as a team first before sending it to OHCQ. She said they are changing their process to report first before they discuss as a team. 9) On 2/3/25 at 11:46 AM a review of facility reported incident MD00209785 documented the Clinical Team Manager (CTM) received from the attending physician a message stating that Resident #620 reported to him about aggressive behavior towards the resident by two staff members. Review of the facility's investigation revealed the allegation was reported to staff on 9/12/24 at 14:47 (2:47 PM). The email confirmation to OHCQ documented that the initial report was sent on 9/13/24 at 9:31 AM, which was not within 2 hours of being reported to staff. On 2/4/25 at 7:47 AM an interview was conducted with the DON #1. The DON #1 stated they talked about it as a team first before sending it to OHCQ. She said they are changing their process to report first before they discuss as a team. 10) On 2/3/25 at 12:58 PM a review of facility reported incident MD00209392 documented that Resident #250 reported to Social Work on 9/2/24 at 11:18 AM that the assigned GNA hurt the resident's private area while cleaning during care and was inappropriate with the resident's private area. Review of the facility's investigation revealed the allegation was reported on 9/2/24 at 11:18 AM, however the email confirmation to OHCQ documented that the initial report was sent on 9/3/24 at 10:00 AM. On 2/4/25 at 7:47 AM an interview was conducted with the DON #1. The DON #1 stated they talked about it as a team first before sending it to OHCQ. She said they are changing their process to report first before they discuss as a team. 44441 11) On 1/28/25 at 1:30 PM, review of a facility reports MD00194158 had that Resident #94 told the activity assistant that s/he did not get enough sleep because their neighbor came to their room and was intimate with him/her, that they must keep it a secret as the spouse was away. Further review of the facility reports on 1/28/25 at 1:40 PM revealed that the resident had a history of severe Dementia and adjustment anxiety disorder. Their Brief interview for mental status (BIMS) score was 6/15 indicative of severe cognitive impairment. An interview with staff revealed that Resident #94 was alert and oriented to self only. S/he was confused, disoriented, and needed a lot of redirections, verbal cueing, and hand gesturing to support needs. Continuing review of the investigative report on 1/28/25 at 1:50 PM revealed that a thorough investigation was carried out. The residents' interviews and assessments, including staff interviews, were also obtained. The abuse allegation was reported to the police and appropriate authorities but was not substantiated. The recreational director received an email about this incident at about 1:17PM however, it did not get reported to the office of health care quality until 5:01PM which was about 4 hours later and more than 2 hours past the stipulated reporting window. On 1/28/25 at 2:00 PM in an interview with the Nursing House Administrator (NHA), he was asked to explain the abuse reporting process. He stated that an abuse should be reported within 2 hours from the time the facility was made aware of the incident. That the expectation is that the facility has a secure message system that includes the physician, executive director, Director of Nursing (DON #1), the clinical excellence team and SW including the actual reporting nurse and they talk about the case first. That most of the time the case will escalate, and they decide if its reportable or not, and then do the investigation. He was asked who was responsible for reporting the incident to the appropriate authorities and he said the reporting was done by Clinical excellence coordinator, NHA or Director of Nursing (DON #1). He was made aware that the incident was not reported timely, he confirmed that it wasn't. 42507 12) On 1/29/2025 at 8:23 AM, review of the investigation report of Facility Reported Incident (FRI), MD00193835, revealed that Resident #229 reported to the bilingual Social Worker on 6/27/2023 at 3:19 PM that the brutish looking person twisted their hand and hit them. Further review of the investigation report of the FRI revealed that the initial self-report of the allegation of abuse was submitted to the State Survey Agency (OHCQ) on 6/27/2023 at 6:21 PM and the local police was notified on 6/27/2023 at 7:00 PM, more than 2 hours past the time the facility staff were made aware of the allegation. Thus, failing to meet the 2-hours reporting requirements for any allegation of abuse. On 1/29/2025 at 1:54 PM in an interview with the Nursing Home Administrator (NHA), the surveyor reviewed the time the facility reported the allegation of abuse to OHCQ and local law enforcement. NHA verified and confirmed that the facility failed to report an allegation of abuse within the required 2-hour window. On 2/7/2025 at 8:34 AM in an interview with the Director of Nursing (DON #2) prior to survey exit, Surveyor reviewed the above FRI with her. DON #2 was informed of surveyor's concerns regarding the facility's failure to timely report an allegation of abuse. No further information was provided. 13) On 1/30/2025 at 10:15 AM, a review of Facility Reported Incident (FRI), MD00192211, revealed that on 5/9/2023 at 11:20 AM, Resident #157 reported to the Violinist that they were raped by a man this morning. A review of the initial self-report revealed the facility notified the police on 5/9/2023 at 3:20 PM and sent the initial self-report to the State Survey Agency (OHCQ) on 5/9/2023 at 3:32 PM, more than 2 hours after facility staff were made aware of the allegation of rape (sexual abuse). Thus, failing to meet the 2-hour reporting requirements for any allegation of abuse. On 2/7/2025 at 8:38 AM, an interview was conducted with the Director of Nursing (DON #2): She reviewed and confirmed that the initial self-report of the above allegation of abuse was submitted to OHCQ on 5/9/2023 at 3:32 PM, more than 2 hours after facility staff were made aware. No additional information was provided. 50904 14) On 1/31/25 at 7:48 AM, the surveyor reviewed the facility's reported incident investigation packet on intake MD00207050, and it revealed that on 06/25/2024 at 2:45 PM, Resident #96 called 911 and reported that the unit secretary Staff #27 twisted his/her hands and pulled away the phone. On 06/25/2024 at 3:24 PM, Clinical Team Manager #3 notified the Director of Nursing (DON 1) and Assistant Director of Nursing #54. Resident Change Evaluator's note on 06/25/24 at 4:28 PM showed: Resident called 911 and reported Unit Secretary pulled away the phone from his/her hands and twisted his/her arms while he/she was sitting in the TV room. He/She called 911 and reported the incident. On 06/25/24 at 7:00 PM, the initial report was sent to the state agency (SA). On 02/03/25 at 08:11 AM, in an interview with the DON 2, when she was asked what the reporting time for an allegation of abuse was, she stated that allegations of abuse should be reported within two hours. She was informed about the reporting time for the incident, and she verbalized that it was past 2 hours of reporting an allegation of abuse. 15) On 02/03/2025 at 7:29 AM, the surveyor reviewed the facility's reported incident investigation packet on intake MD00193633, and it revealed that, on 06/20/2023 at 2:21PM, Resident #278 had reported to the Clinical Team Manager #53 that CNA #52 who had him/her the previous night was very rude, did not help him/her position his/her legs, told the resident he/she was too demanding and did not want to hear his/her call light for the next three hours. Spoke down on him/her and was in tears. On 06/20/2023 at 3:29 PM, Director of Nursing (DON 1) and Assistant Director of Nursing were made aware. On 06/21/2023 at 10:06 AM, the matter was reported to the state agency (SA). On 02/03/25 at 08:11 AM, in an interview with the DON 2, when she was asked what the reporting time for an allegation of abuse was, she stated that allegations of abuse should be reported within two hours. She was informed about the reporting time for the incident, and she verbalized that it was past 2 hours of reporting an allegation of abuse. 51213 16) On 1/31/2025 at 01:10 PM the Director of Nursing (DON #1) was shown some notes from the facility reported incident and was asked if these notes were from their internal risk management system? DON #1 replied, yes, these notes are from our internal risk management system and are available upon request. DON #1 was then asked if the facility filed the self-report MD#00209782 to the Office of Healthcare Quality (OHCQ) on 9/12/2024 at 5:18PM? DON #1 replied, yes we reported this incident to OHCQ on 9/12/2024 at 5:18 PM. DON# 1 was then shown that their internal risk management report and the self-report sent to OHCQ documented stated that resident #264 reported an allegation of abuse to a Social Worker, Staff # 62 at 12:33 PM on 9/12/2024. DON #1 was notified of the alleged abuse at 12:46 PM on 9/12/2024, and the facility incident report was sent to OHCQ on 9/12/2024 at 5:18PM. DON #1 was then asked what time frame should an allegation of abuse be reported to OHCQ? DON #1 replied within two hours. DON #1 was then asked if this incident MD#00209782 was reported within two hours. DON #1 replied no it was not. 51789 17) On 2/4/2025 at 11:25 AM, the Surveyor reviewed a facility-reported incident, MD00206760. It was revealed that on 6/17/2024 at 2:45 PM, Resident # 77 reported that his/her left middle finger was bruised and painful because a resident pushed a walker to his/ her and hit the left middle finger. Further review of the facility's investigation revealed that the facility submitted the incident's initial report to OHCQ (Office of Health Care Quality) on 06/17/2024 at 6:20 PM, 4 hours later upon learning of the incident. On 2/4/2025 at 1:50 PM, an interview was conducted with the Director of Nursing (DON # 1). The Surveyor reviewed the facility-reported incident with her, DON # 1 verified the date and time of incident including the time the initial report was submitted to OHCQ. DON # 1 also added that because it was a resident-to-resident incident, we did not know it had to be reported within 2 hours from when the allegation was found. DON # 1 acknowledged that they submitted the initial reporting late. 47200 18) On 02/04/25 at 2:30 PM the surveyor conducted a review of the facility's complete investigation file for #MD00213385 regarding Resident #48 who had reported an allegation of abuse. Review of the investigative file revealed documentation that the resident's family member informed the facility of the resident's allegation of abuse on 1/7/25 via a voicemail which was received by Social Worker #67 on 1/8/25. Review of the initial self report made to the Office of Health Care Quality revealed the report was documented as made on 1/9/25 at approximately 9:50 AM. Review of the medical record by the surveyor on 2/6/25 at 4:05 PM revealed a note documented by Social Worker #67 on 1/8/25 at 11:32 AM indicating they had made contact with the resident's family member that morning in response to receiving their voicemail. On 2/4/25 at 2:42 PM the surveyor conducted an interview with the Director of Nursing (DON #1) who confirmed with the surveyor that the allegation of abuse was not reported within the required two hour time frame. They further confirmed they had no further documentation to provide regarding the timing of the initial self report made to the Office of Health Care Quality.

Based on review of facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 9 (#629, #638, #640, #366, #625, #5, #622, #87, and #619) residents of 60 facility reported incidents reviewed during a recertification/complaint survey. The findings include: The Minimum Dats Set (MDS) is a standardized and comprehensive assessment screening tool used to identify resident's individual needs and areas of concern. BIMS stands for Brief Interview for Mental Status. It is a screening tool used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur. 1) On 1/28/25 at 11:30 AM a review of facility reported incident MD00167904 was conducted and revealed a Clinical Team Manager received an email on 5/31/21 that stated on 5/30/21 around 2pm, Resident #629 complained to a musical therapist that he/she was raped 3 weeks ago. Review of the facility's investigation revealed that 36 staff were interviewed, however there were no resident interviews from the unit where Resident #629 resided. On 2/3/25 at 2:15 PM an interview was conducted with the DON #1. The DON confirmed that there was no resident interviews found in the investigative packet given to the surveyor. 2) On 1/29/25 at 8:10 AM a review of facility reported incident MD00195669 was conducted and revealed Resident #638 alleged that someone had punched the resident 3 times in the face the night before. Review of the facility's investigative packet that was given to the surveyor on 1/29/25 revealed there were (9) staff members that had worked with the resident that were interviewed. There were no resident interviews from residents that resided on the same unit to ask if they felt safe or had any abuse concerns with staff members. On 1/29/25 at 12:11 PM an interview was conducted with the Director of Nursing (DON #1). The DON #1 checked to see if the social worker had emailed resident interviews for the intake and confirmed that she did not have any resident interviews. 3) On 1/29/25 at 11:00 AM a review of facility reported incident MD00194021 was conducted and revealed Resident #640 alleged that a GNA was very rough when cleaning the resident during incontinence care. A review of the facility's investigation revealed an interview with the accused GNA along with a background check from the agency that the GNA was contracted from. There were no resident interviews from the agency GNA's assignment included in the investigation. On 1/29/25 at 12:11 PM an interview was conducted with the DON #1. The DON #1 checked to see if the social worker had emailed resident interviews for the intake and confirmed that she did not have any resident interviews. The DON confirmed it was an incomplete investigation. 4) On 1/29/25 at 11:49 AM a review of facility reported incident MD00206126 was conducted and revealed during the night shift on 5/26/24 Resident #366 alleged that a tall man came into the resident's room and changed the resident's diaper, and the resident stated he/she did not wear a diaper. Review of the facility's investigation revealed a written statement from the agency geriatric nursing assistant (GNA) and (7) resident interviews, however there were no other staff interviews included in the investigation. On 2/3/25 at 8:11 AM an interview was conducted with the DON #1. The DON #1 confirmed that there were no other staff interviews. The DON #1 stated, the agency GNA was interviewed and another GNA from our staff. The Social Worker stated that she interviewed others but there was no documentation. 5) On 2/3/25 at 10:15 AM a review of facility reported incident was conducted and revealed Resident #625's family member alleged that Resident #625 had been slapped on 3/2/23 and 3/3/23 by staff. Review of the facility's investigation revealed that 16 staff members were interviewed, however there were no other residents on the unit that were interviewed. On 2/4/25 at 7:45 AM the DON #1 was interviewed and confirmed there were no other resident interviews from the GNA's assignment. 6) On 2/3/25 at 11:20 AM a review of facility reported incident MD00194070 was conducted and revealed Resident #5 alleged to his/her son that Resident #5 had been hit on the back and arm by staff during care. Review of the facility's investigation revealed a statement from the GNA that was taking care of Resident #5, however there were no other staff interviews included in the investigation. On 2/4/25 at 9:57 AM an interview was conducted with the DON #1. The DON #1 confirmed that they did not have any other documented interviews of staff. 7) On 2/4/25 at 8:50 AM a report of facility reported incident MD00182370 was conducted and revealed Resident #622 alleged that he/she was sexually assaulted the previous evening on 2/10/22. A review of the facility's investigation revealed staff were interviewed but there were no other residents on the unit that were interviewed. On 2/4/25 at 9:57 AM an interview was conducted with the DON #1. The DON #1 confirmed that they did not have any other documented interviews of residents on the unit. 43096 8) During an investigation of the facility self-reported incident, MD00206059, on 1/28/25 at 8:25 AM, it revealed that Resident #87 reported on 5/26/24 that a Geriatric Nursing Aide ( GNA #57) who was assigned to him/her violated the resident's rights, including turning off the call light, leaving the room, and not asking what the resident needed when they provided care to Resident #87. Further review of the facility's investigation regarding this report showed that the facility conducted a phone interview with GNA #57 and resident interviews, including Resident #87 and other residents. However, the facility did not have interviews with other staff to support their thorough investigation. In an interview with the Director of Nursing (DON #1) on 1/28/25 at 11:04 AM, she stated that the facility interviewed residents, perpetrators, and other staff while they were investigating the resident's abuse case. The surveyor reviewed Resident #87's abuse case with the DON. She said, I will search for other staff interviews for this case. On 1/30/25 at 2:41 PM, the DON #1 confirmed that the facility could not find other staff interviews for this reported incident. She validated the surveyor's concern that this investigation was not thoroughly performed. 44441 9) On 2/4/25 at 9:00 AM, review of incident #MD00181518 had that Resident #619 told a family member who reported to the charge nurse, that, a male Geriatric Nursing Assistant (GNA) who gave resident a bath in the morning fondled their breast. The charge nurse reported the incident to the Clinical Team Manager. Review of Resident #619's MDS Section C (Cognition) on 2/4/25 at 9:15 AM with Assessment Reference Date (ARD) of 7/8/22 documented a BIMS score of 99 indicating that resident was unable to complete the interview. Review of the mental status assessment form, Section C1000 dated 7/7/22 documented that resident was severely impaired. The Resident also has a care plan for impaired cognitive function. Review of the investigative report done by the facility on 2/4/25 at 9:30 AM revealed that a thorough investigation was not conducted. The resident was assessed and no issues found except for old bruises from prior falls. The alleged staff member was immediately suspended and investigation started. The police, ombudsmen and the office of Health Care Quality (OHCQ) immediately notified. The resident, staff, and witness interviews were also obtained however, other resident's interviews could not be found. On 2/4/25 at 9:50 AM in an Interviews with the Director of Nursing (DON #1) she was made aware that other resident interviews could not be found and asked to verify. She checked the investigative report folder but could not find the missing document. She stated that if it's not in the folder, then it was not done. She was made aware that this was a concern.

Based on observation, interview and record review it was determined the facility failed to: 1.) ensure the labeling, dating, and expiration of nourishment items, 2.) ensure a sanitary environment in the nourishment refrigerator and 3.) ensure dishwashing machines met the minimum required manufacturer temperatures recommended for sanitization. This was evident for: 1.) 1 reach-in refrigerator in 1 out of 2 of the facility's kitchens, 2.) 1 nourishment refrigerator in 1 out of 2 of the facility's kitchens, and 3.) 3 out of 4 dishwashing machines, during the facility's recertification/complaint survey. The findings include: 1.) On 1/27/25 at 8:11AM during the surveyor's initial tour of the facility's kitchens, the surveyor observed the reach-in refrigerator located in the main kitchen which contained trays containing the following items which had no labeling or dates present to indicate preparation or expiration dates: plates of orange slices, cold salad sandwiches, approximately 14 individual containers of fruit with cream base, approximately 27 individual containers of cottage cheese, a metal pan of cold meat type salad with a plastic scoop cup located within the salad. On 1/27/25 at 8:27AM the surveyor requested a dual observation and shared concerns with Senior Dining Director, Certified Dietary Manager (CDM) #61 who observed the concerns. At this time the surveyor conducted an interview with CDM #61 who stated the following information to the surveyor: Items should be labeled and dated prior to storing in the refrigerator. At this time, they were unable to confirm with the surveyor as to when the foods had been prepared or were to expire. During the dual observation on 1/27/25 at 8:30AM a tray of cheese sandwiches was additionally observed in the reach-in refrigerator with the following label which read: prepared food, reheated, nourishment, prepared 1/13/25 11:56AM, discard by 1/16/25 11:56AM. When the surveyor inquired as to the labeling and expiration of this tray of sandwiches, CDM #61 proceeded to throw the items away into the trash can. 2.) On 1/27/25 at 8:14AM the surveyor observed the main kitchen's nourishment refrigerator which was found to contain a cardboard box in which various condiment packets including sugar and sugar substitute packets, tea bags etc. were observed sticking out of the box with visible circular spots of black, brown, and green matter. A container of soymilk was observed within the same nourishment refrigerator with the following labeling affixed to it: prepared 1/16/25 11:47AM, discard by 1/19/25 11:47AM. On 1/27/25 at 8:20AM the surveyor conducted an interview with Project Manager (PM) #63 who confirmed they were the interim person overseeing the kitchen at the present time until a new person was to begin employment. At this time, the surveyor requested a dual observation of the nourishment refrigerator with PM #63, who observed, confirmed, and acknowledged the surveyor's concerns. When the surveyor inquired as to what would be done with the items, PM #63 stated the following information: I'm going to throw them away. At this time, the surveyor observed them throw the items into the trash can. On 1/27/25 at 8:27AM the surveyor requested a dual observation and shared concerns with Senior Dining Director, Certified Dietary Manager (CDM) #61 who observed the concerning contents within the trash can. At this time, CDM #61 acknowledged and confirmed understanding of the surveyor's concerns. 3.) On 1/29/25 at 11:40AM the surveyor conducted an observation of the main kitchen's dishwashing machines. It was observed at this time that the meat dishwashing machine was under repair. On 1/29/25 at 1:39PM the surveyor conducted an observation of the main kitchen's dairy dishwashing machine while in operation and observed 3 out of 3 dials failed to be in working order as dishes were put through the machine, the needle was not moving to display the machine's temperatures. At this time, the surveyor conducted an interview of Maintenance Associate (MA) #64 to understand why the dials were not moving during the continued operation of the machine while it was actively washing dishes. At this time, MA #64 observed the dials which were not moving, and then they were observed pushing on the sliding door of the dishwasher with their hand. MA #64 then showed the surveyor that the pressure gauge was rising and the dials were now moving. Continued observation of the dials revealed the final rinse temperature did not meet the minimum required temperature of 180 degrees Fahrenheit as observed on the machine's manufacturer recommendations located on the machine's plackard and labeling and was labeled for being . The highest the dial was observed to read for the final rinse temperature in response to MA #64 having pushed on the door to the machine during operation of the dishwasher was 164 degrees on 1/29/25 at 1:39PM. When the surveyor further inquired as to why the machine could not sustain temperatures to MA #64, they stated the following information to the surveyor: There is a censor issue. MA #64 opened the door they had pushed on and showed the surveyor the censor that was located within it which they confirmed was malfunctioning and needed replacement. At this time, the surveyor shared their concerns. On 1/29/25 at 2:00PM the surveyor requested a dual observation with Director of Dining Services #65 who observed and confirmed that the dials for the dairy dishwashing machine were not moving unless MA #64 pushed on the door of the machine. On 1/29/25 at 2:00PM the surveyor conducted an interview with DODS #65 who stated the following information to the surveyor: The dishwashers constantly have repairs because of the equipment and kitchen's age. On 1/29/25 at 2:12PM the surveyor was approached by the Director of Building Services (DOBS) #66 who observed the dishwasher in operation and confirmed with the surveyor that the machine was not reaching the minimum required temperatures for wash (160F) or final rinse (180F) at this time. The wash temperature was observed to be at 158F and the final rinse temperature was observed to be at 148F. On 1/29/25 at 2:16PM MA #64 showed CDM #61, DOBS #66, DODS #65, and the surveyor that the censor was not working, and unless they pressed on the door of the machine which then caused the pressure gauge to raise and temperatures to increase, the required temperatures could not be met. On 1/29/25 at 2:19PM CDM #61 reported to the surveyor that they would not be utilizing the dishware at this time and would hold the dishware to re- run through the dishwasher after the repairs have been completed. On 1/29/25 at 2:26PM the surveyor conducted a dual observation with CDM #61 in the facility's additional kitchen located in a separate building. At this time, the dairy dishwasher machine in the additional kitchen was observed to not be meeting the minimum required manufacturer temperatures for wash and final rinse. During the machine's operation the temperature gauges were observed to be at 150F for the wash and 151F for the final rinse. Observation of the machine's plackard indicated the following manufacturer recommendations for minimum temperatures: 160F for wash, and 180F for final rinse. On 1/29/25 at 2:30PM CDM #61 the meat dishwasher located in the additional kitchen was put into operation by CDM #61 and it was observed that the wash temperature gauge was not consistently moving above 150F while dishes were being put through the machine, and the final rinse temperature was 176F. The machine was observed to not be able to consistently meet required temperature requirements. During an interview of CDM #61 on 1/30/25 at 11:40AM, after surveyor intervention, they reported to the surveyor that two fuses were found to be blown in the additional kitchen's dairy dishwasher booster which were repaired. The surveyor observed the dishwasher temperatures which were found to be meeting the required temperatures, and CDM #61 reported they were now resuming use of the dishwasher. On 1/30/25 at 11:44AM the surveyor observed the additional kitchen's meat dishwasher with CDM #61 while it was in operation and observed the wash temperature to be 140F which was not meeting the machine's manufacturer recommendation on the plackard for a minimum required temperature of 160F. On 1/30/25 at 11:44AM CDM #61 stated the following to the surveyor: It wasn't apparent that there was an issue with this one. On 1/30/25 at 11:49AM the surveyor continued to interview CDM #61 who reported to the surveyor that the main kitchen's dairy dishwasher was still being worked on and that there was no solution yet. On 1/30/25 at 11:49AM the surveyor observed CDM #61 shut the run button off for the meat dishwasher in the additional facility kitchen off, which then increased the wash temperature to 158F. At this time, the surveyor shared all dishwashing concerns with CDM #61 and confirmed that all dishwashers within the two buildings were using heat mode of sanitization. CDM #61 confirmed understanding and acknowledged the surveyor's concerns at this time. On 2/7/25 at 12:30PM the concern was shared with the facility's Administrator and Director of Nursing during the facility's exit conference.

Based on medical record review and interview, it was determined that the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 9 (Resident #366, #63, #367, #615, #626, #628, #644, #649, and #650) resident of 108 residents reviewed during the recertification/complaint survey. The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 1/29/25 at 11:49 AM a review was conducted of Resident #366's medical record. Review of the miscellaneous section of the medical record revealed a Hospital Transfer summary for another resident, Resident #367 dated 5/16/24. There were 2 transfer summary entries. There were 22 pages of medical information on the first transfer summary that included Resident #367's name, medical record number, date of birth, patient demographics, medical diagnoses, medications, laboratory results, past medical history, and current medical history. The second transfer summary consisted of 61 pages of medical information that included progress notes from the in hospital stay, summaries, and diagnostic results. On 2/3/25 at 8:11 AM an interview was conducted with the Director of Nursing (DON #1). The DON #1 was shown the electronic medical record where Resident #367's transfer summary was loaded into Resident #366's medical record. The DON asked who uploaded it into the medical record and she confirmed the unit secretary uploaded the transfer summary into the wrong medical record. 34484 2) The facility staff failed to document the administration of narcotic medications on residents' Medication Administration Records for Resident #615, #626, #628, #644, #649 and #650. Review of facility provided documentation on 2/3/25 revealed on 4/29/24 the Director of Nursing #1 (DON) received report from the Assistant Director of Nursing (ADON) of RN #17's medical emergency on 4/10/24 at 2:00 PM and resignation on 4/12/24 via text message. On 4/29/24 the DON began a review of residents' Controlled Medication Utilization Record and medications documented on residents' MARs (Medication Administration Records) for narcotics. a) Review of Resident #615's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS (Brief Interview of Mental Status) of 15 of 15, cognitively intact. Further review of Resident #615's April 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Oxycodone 5 mg on 4/10/24 at 7:55 AM, 11:57 AM and 3:59 PM. Review of Resident #615's April 2024 MAR revealed the Oxycodone 5 mg on 4/10/24 at 7:55 AM, 11:57 AM and 3:59 PM were not documented as administered to the Resident. Further review of the facility investigation revealed the DON interviewed the Resident on 4/29/24 but the Resident could not recall how many doses he/she received of Oxycodone on 4/10/24. b) Review of Resident #644's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS of 8 of 15, moderate cognitive impairment. Further review of Resident #644's April 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Oxycodone 5 mg on 4/10/24 at 10:55 AM, 2:55 PM and 6:55 PM. Review of Resident #644's April 2024 MAR revealed the Oxycodone 5 mg on 4/10/24 at 10:55 AM, 2:55 PM and 6:55 PM were not documented as administered to the Resident. Further review of the facility investigation revealed the DON interviewed the Resident on 4/29/24 but the Resident could not recall how many doses he/she received of Oxycodone on 4/10/24. c) Review of Resident #650's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS of 15 of 15, cognitively intact. The Resident was then discharged from the facility on 3/9/24. Further review of Resident #650's March 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Tramadol 50 mg on 3/3/24 at 7:55 AM, 3/7/24 at 7:55 AM and 3/8/24 at 7:55 AM and 12:00 PM. Review of Resident #650's March 2024 MAR revealed the Tramadol 50 mg on 3/3/24 at 7:55 AM, 3/7/24 at 7:55 AM and 3/8/24 at 7:55 AM and 12:00 PM were not documented as administered to the Resident. d) Review of Resident #649's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS of 10 of 15, moderate cognitive impairment. The Resident was then discharged from the facility on 4/8/24. Further review of Resident #649's March and April 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Oxycodone 5 mg on 3/21/24 at 8:00 AM, 3/26/24 at 7:55 AM, 3/26/24 at 11:59 AM and 4/4/24 at 8:00 AM. Review of Resident #649's March and April 2024 MAR revealed the Oxycodone 5 mg on 3/21/24 at 8:00 AM, 3/26/24 at 7:55 AM, 3/26/24 at 11:59 AM and 4/4/24 at 8:00 AM were not documented as administered to the Resident. e) Review of Resident #628's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS of 14 of 15, cognitively intact. The Resident was then discharged from the facility on 3/13/24. Further review of Resident #628's March 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Oxycodone 5 mg on 3/2/24 at 12:10 PM, 3/3/24 at 11:57 AM and 3/7/24 at 11:55 AM. Review of Resident #628's March 2024 MAR revealed the Oxycodone 5 mg on 3/2/24 at 12:10 PM, 3/3/24 at 11:57 AM and 3/7/24 at 11:55 AM were not documented as administered to the Resident. f) Review of Resident #626's medical record on 2/3/25 revealed the Resident was admitted to the facility on [DATE] and was assessed by staff to have a BIMS of 10 of 15, moderate cognitive impairment. The Resident was then discharged from the facility on 3/14/24. Further review of Resident #626's February and March 2024 Controlled Medication Utilization Record revealed Staff #17 signed out Oxycodone 5 mg on 2/3/24 at 12:40 PM, 2/4/24 1:19 PM, 2/8/24 at 7:55 AM, 12:15 PM, 5:00 PM, 2/9/24 at 1:00 PM, 6:20 PM, 2/14/24 at 11:54 AM, 2/17/24 at 12:00 PM, 2/18/24 at 12:12 PM, 2/22/24 at 7:50 AM, 2/23/24 at 12:07 PM, 2/26/24 at 12:55 PM, 2/27/24 at 1:00 PM, 2/28/24 at 1:12 PM and 3/2/24 at 12:10 PM. Review of Resident #626's February and March 2024 MAR revealed the Oxycodone 5 mg on 2/3/24 at 12:40 PM, 2/4/24 1:19 PM, 2/8/24 at 7:55 AM, 12:15 PM, 5:00 PM, 2/9/24 at 1:00 PM, 6:20 PM, 2/14/24 at 11:54 AM, 2/17/24 at 12:00 PM, 2/18/24 at 12:12 PM, 2/22/24 at 7:50 AM, 2/23/24 at 12:07 PM, 2/26/24 at 12:55 PM, 2/27/24 at 1:00 PM, 2/28/24 at 1:12 PM and 3/2/24 at 12:10 PM were not documented as administered to the Resident. Interview with the Director of Nursing (DON) #1 on 2/4/25 at 12:00 PM confirmed Staff #17 failed to accurately document the administration on narcotic medications for Resident #615, #644, #650, #649, #628 and #626. 47200 3) On 2/3/25 at 12:50PM the surveyor conducted a review of the medical record for Resident #63 which revealed the following two separate medical orders for medications which were incomplete without an indication for use specified: a.) Seroquel Oral Tablet 25 MG, give 0.5 tablet by mouth one time a day, and b.) Amlodipine Besylate Oral Tablet 5 MG, give 1 tablet by mouth one time a day. On 2/4/25 at 9:50AM the surveyor reviewed prior recommendations made by Pharmacist #49 on 9/16/24 and 1/14/25, which included the need for diagnoses and/or indications for use of medications needing to be present within medical orders. On 2/4/25 at 10:14AM the surveyor conducted an interview with Clinical Team Manager (CTM) #50 who confirmed with the surveyor that when creating a medical order for medications, they could utilize either the diagnoses box or the indication for use box in which either would populate the indication for use in the medication order. The surveyor observed the medication orders for Resident #63's Amlodipine and Seroquel with CTM #50 who confirmed with the surveyor that the medication order did not display the indication for use and the diagnosis they had selected for indication of use was not populating to show on the medical order. CTM #50 further confirmed with the surveyor that they enter medication orders in response to pharmacy recommendations after the physician or nurse practitioner has reviewed the recommendations and provided a response. At this time, the surveyor shared their concern that the medical orders did not display an indication for use. CTM #50 acknowledged understanding of the surveyor's concern. On 2/4/25 at 10:39AM the surveyor conducted an interview with the Director of Nursing (DON #1) who confirmed with the surveyor that staff can either select related diagnoses or complete the indication for use box when creating a medical order. The DON #1 reported the following information to the surveyor: I did not know this was not showing under the order, we need to make sure we have the indication for use, most people use the indication section, so we did not know it wasn't showing up on the medical order, I review these and did not see these missing the indications.

Based on observation, medical record review, and interviews with the staff and resident, it was determined that the facility failed to ensure the Comprehensive Minimum Data Set (MDS) assessments accurately reflected the resident's oral/dental status. This was found to be evident in 1 (Resident # 269) of 4 residents reviewed for the MDS assessment during the recertification/complaint survey. The findings include: The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments must be accurate to ensure each resident receives the appropriate care they need. On 01/31/25 at 10:59 AM, Resident # 269's medical record was reviewed. The resident was initially admitted in February 2024 to the facility after undergoing abdominal surgery. Around mid-April 2024, the resident was hospitalized due to high ostomy output and readmitted to the facility on [DATE]. On 1/31/2024 at 11:30 AM, a review of the MDS(Minimum Data Set) Comprehensive Assessment Section L - Oral/Dental Status dated 3/31/2024 and 4/26/2024 respectively was coded to have no oral or dental concern. On 1/31/2024 at 11:45 AM, a review of the Nursing admission assessment dated [DATE] revealed that it was documented the presence of own teeth, and the re-admission nursing assessment dated [DATE] documented the presence of a lower denture. On 1/31/2024 at noon, a review of the physician order identified an order created on 4/23/2024 that showed Patient admitted with partial lower denture please assist to apply in the morning and remove at bedtime every day and night shift. During an interview with Resident #269 on 01/31/25 at 01:03 PM, the resident stated he/she used to have both upper and lower dentures, however, before his/her initial admission to this facility, his/her upper denture was broken during a hospital procedure. The resident said, During my re-admission to this facility, I had my lower denture, but now the lower denture was broken and I have missing upper and lower teeth. On 1/31/2024 at 1:10 PM, the surveyor observed Resident #269 and verified that he/she did not have upper or lower dentures, with broken and missing upper and lower teeth. On 02/05/25 at 1:27 PM, the MDS manager (Staff # 48) was interviewed, and she explained the process of doing the MDS (Minimum Data Set) Comprehensive Assessment. She stated that the first step was to open the assessment and plot the date for the ARD (Assessment Reference Date) then for each section of the assessment, a record review will be done, then a resident interview and physical assessment related to pain, vision, hearing and oral condition will be conducted. Staff # 48 stated that she performed a record review, an interview, and a physical assessment of Resident #269 on both scheduled MDS Comprehensive Assessments dated 3/1/2024 and 4/26/2024 respectively. Staff # 48 acknowledged the presence of lower dentures based on the Nursing Admission assessment dated [DATE]. Staff # 48 also confirmed that in section L of both Comprehensive assessments with ARD 3/1/2024 and 4/26/2024, no oral or dental issue was coded. On 02/07/25 at 12:30 PM, during the exit conference, the MDS concern was discussed with the Administrator and the Director of Nursing.

Based on record review and interviews, it was determined that the facility failed to thoroughly develop and implement a comprehensive person-centered care plan that addresses resident's medical, nursing, and mental and psychosocial needs that was identified in the admission comprehensive assessment. This was evident for 1 (Resident #89) of 4 residents care plans reviewed during the recertification/complaint survey process. The findings include: On 01/28/25 at 09:54 AM, in an interview with the resident's (Resident #89) representative, it was expressed to the surveyor that on 1/27/25 the resident had an episode of incontinence, the resident representative stated that the staff was notified of the resident's incontinence; however, incontinence care was not provided until a couple of hours later. On 01/29/25 at 11:23 AM, a review of the Geriatric Nursing Assistant (GNA) task list for Resident #89 in the month of January 2025 revealed that incontinence care was documented once on 1/27/25 at 1:36 AM. On 01/29/25 at 11:23 AM, review of the medical record revealed that the resident was a readmission in January 2025. A review of Resident #89's comprehensive care plan revealed that the care plan was not person-centered and it failed to identify and address all the services and interventions needed to attain or maintain the resident's highest practicable physical, mental, and psychosocial health. On 01/29/25 at 11:41 AM, in an interview with RN #55, she stated that the GNAs provide scheduled incontinent care and GNA usually does the incontinent care in the morning, after the start of shift, in the afternoon and as needed on day shift. She confirmed that the GNA was expected to document incontinent care on the GNA task list. RN #55 was also asked who was responsible for updating the care plan and she stated that every nurse can update the care plan as needed. RN#55 was then shown Resident #89's care plan and the surveyor expressed the concern that it did not reflect the care needs of the resident and she stated the care plan needs to be updated. On 01/30/25 at 09:45 AM, in an interview with RN #70, unit manager was asked who was responsible for updating the care plan and she stated the floor nurses and the nurse managers were responsible for updating the care plan. She stated that care plans were updated initially within 30 days, as needed with any change and 90 days with the admission assessment. Resident #89's care plan was reviewed with RN#70 and she was informed that the care plan does not reflect the resident's personal care needs nor all active diagnoses and interventions/treatments that will be provided to meet the care needs of the resident. On 01/30/25 at 12:35 PM, in an interview with the Director of Nursing (DON #1), she was informed of the above-mentioned findings and she stated that the comprehensive care plan was initiated; however; the unit manager was responsible for the care plan review and it was missed.

Based on medical record review and interview, the facility staff failed to notify a resident's physician and/or responsible party for a change in status in a timely manner (Resident #630, #643). This was evident for 2 of 108 residents reviewed during a recertification/complaint survey. The findings include: 1) The facility staff failed to notify Resident #630's physician and responsible party for changes in the Resident's pressure ulcer. Review of Resident #630's medical record on 1/29/25 revealed on 3/20/23 the Resident was assessed to have a Stage II sacral pressure ulcer. Further review of Resident #630's medical record revealed on 3/30/23 the Resident was assessed by the Wound care doctor to have a Unstageable sacral pressure ulcer. A) Further review of Resident #630's medical record revealed the Wound care doctor saw the Resident weekly except for 4/20/23, 7/3/23, 7/10/23, 7/27/23, 8/3/23 and 8/17/23. On those dates there is no documentation in the medical record the facility staff reviewed the Resident's wound status with Staff #58 (Primary physician) to determine if the wound treatment needed to be changed. B) Review of Resident #630's wound care orders revealed the sacral pressure ulcer treatment was changed on the following dates: 4/27/23, 5/18/23, 5/25/23, 6/1/23, 6/8/23, 7/20/23 and 8/10/23. Further review of the medical record revealed no documentation that the facility staff notified the Resident's responsible party of the wound care order changes. Interview with the Director of Nursing #1 on 1/31/25 at 8:19 AM confirmed the facility staff failed to notify the Resident's primary physician of the sacral pressure ulcer assessments when the Wound care doctor was not available and failed to notify the Resident's responsible party when the Resident's sacral pressure ulcer wound treatment orders were changed. 2) The facility staff failed to notify Resident #643's physician timely when the Resident had a fall with injury on 6/13/24. Review of Resident #643's medical record on 2/3/25 revealed the Resident had a fall on 6/13/24 at 5:45 PM with an initial neuro assessment at 5:45 PM. Further review of the Resident's medical record revealed notification of the fall was not sent to the doctor until 6/13/24 at 6:44 PM, 1 hour after the fall. The notification stated, patient was observed on the floor near the toilet and had injury on the right elbow with tunneling 2 cm by 1.2 cm by 1 cm, he/she also hit his/her head on the floor, no sign of hematoma present. Patient stated that his/her daughter is coming to take him/her to the hospital to get suture on elbow please advise. Further review of Resident #643's medical record revealed a hospital transfer note on 6/13/24 at 7:11 PM that stated, Patient was observed on the floor near the toilet and had injury on the right elbow with tunneling 2 cm by 1.2 cm by 1 cm, he/she also hit his/her head on the floor, no sign of hematoma present, and right hip. Gauze dressing apply Patient was seen by the shift supervisor and suture is needed for the right elbow, patient is transferred to the hospital for more assessment. Interview with Director of Nursing #1 on 2/4/25 at 8:00 AM confirmed the facility staff did not notify the Resident's physician until 1 hour after a fall with injury on 6/13/24.

PNC IJ 689 Based on surveyor review of clinical and administrative records and staff interviews, it was determined that the facility failed to put interventions in place to address the resident's wandering behavior and accurately assess the resident for the risk of elopement. As a result of this deficient practice, a cognitively impaired resident was able to exit the facility twice without staff knowledge or supervision, once on 7/21/2021 and again on 10/3/2021. The resident was found on 10/3/2021 near a busy road in close proximity to the facility. This finding was evident for 1 of 2 residents reviewed for elopement during a complaint survey and was identified during the investigation of facility reported incidents #MD 877 and MD 768. Evidence was provided by the facility that an action plan was developed, and corrective measures were implemented on 10/3/2021 immediately after the incident, to remove the immediacy of the noncompliance and correct the deficient practice. On 7/15/2022, a determination of immediate jeopardy was made regarding the deficient practice with the potential for past non-compliance. The Administrator and Director of Nursing were informed at 3:50 PM. Review of all facility corrective actions implemented prior to the survey start date, revealed that the facility had met minimum standards for plans of correction and the concern was therefore deemed past noncompliance. The findings include: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so (State Operations Manual F689). Facility reported incident (FRI) # MD 877 was reviewed on 7/7/2022 for resident safety. According to the facility report, Resident #2 was found by the police out of the facility on 7/21/2021 and brought back to the facility. On 7/7/2022, review of progress notes dated 7/21/2021, revealed the following nursing documentation at 1PM: Resident with a history of going off the unit to sit outside for fresh air was observed by a local police officer at a location away from the facility. The police officer alerted the unit by phone and later drove the resident in his cruiser back to the facility. Upon return to the facility, the Clinical Team Manager and the Charge Nurse completed a head-to-toe assessment, including vital signs and no injuries or unusual changes were noted. Further review of the FRI revealed that, per camera footage on 7/21/2021 at 10:48 AM, the resident left the building, and at 10:55 AM, the resident was seen exiting the building to the left heading towards the garden exit on 1 east. A local Police officer called the facility regarding the resident's whereabouts at 12:32 PM on the same date. Review of Resident #2's medical record on 7/7/2022 revealed that the resident's diagnoses included, but were not limited to: [CONDITION(S)], Dementia, [CONDITION(S)], [CONDITION(S)], Depression, and Tobacco use. Resident #2's Brief Interview of Mental Status (BIMS) assessments dated 6/25/2021 and 9/25/2021, revealed that he/she scored 6 out of 15. BIMS score on 10/4/2021 was 4 out of 15. A score of 0 to 7 indicates severe impairment. On 7/8/2022 a review of FRI # MD 768 revealed that, on 10/3/2021 at 5 PM, Resident # 2 was noted not to be in their room. At that time, facility staff was alerted and began a search on the unit and all the units in the building. The Leadership Team reviewed the camera footage which indicated that the Resident was in the lobby at 2:09 PM. The local police were notified, and a search of the facility and surrounding area was conducted. Resident #2 was located later that night at about 8 PM by a facility staff near a busy street and brought back to the facility. Written statements obtained from staff during the facility's investigation revealed that staff on the unit did not observe the resident leave the unit. After staff brought the resident back to the building on 10/3/2021, s/he was placed on a 15-minute monitoring protocol. Education was provided for unit staff, front desk staff, and the private duty aide on Resident #2's care and de-escalation techniques. Resident was added on the elopement list and his/her care plan updated. On 7/8/2022 at 9:44 AM, an interview was completed with Geriatric Nursing assistant (GNA #7) who had worked in the facility for over [AGE] years. GNA #7 stated that Resident #2 was very independent and would leave the floor but would always come back. GNA #7 stated that the resident did not like people approaching them and would be upset sometimes. GNA #7 further stated that she worked with Resident #2 on the day s/he left the building, but could not recall anything about the incident. GNA #7 stated that Resident #2 did not have a wander guard on because s/he would take off the wander guard bracelet whenever they attempted to put one on her/him. On 7/8/2021 at 2:55 PM, review of the facility Elopement incident report (# ) , dated 10/3/2021, noted under other Info that: Resident #2 enjoys being outside taking long walks. S/he does not like to notify staff when s/he wants to walk outside of the facility. Due to his/her cognitive deficits related to a [CONDITION(S)], his/her safety is at risk when s/he leaves the facility unsupervised. On 7/11/2022 at 1:55 PM, during an interview with the Front Desk Receptionist (FDR #6), who had worked in the facility for [AGE] years, she stated that she did not recall the above incidents on 7/21/2021 and 10/3/2021. However, FDR #6 said that she remembered an incident once when a resident left the building, and the Police were called. She could not give the specifics of that incident. Regarding resident monitoring, FDR #6 stated that the residents who were independent did not have to notify the front desk staff when going outside. However, those that had the wander guard would set off the alarm if they attempted to leave the building. They have pictures of residents who are at risk for elopement posted on the front desk and staff keeps an eye for those residents. FDR #6 further stated that those residents have the wander bracelet on. When asked if a resident who was at risk for elopement, but did not have the wander guard bracelet were to leave the building, how would she detect that? FDR #6 stated it would be very difficult to identify a resident like that, especially during busy times. However, FDR #6 stated that there was a camera at the front lobby door and the supervisor could look at the footage if there was a situation where a resident left the building unnoticed. On 7/12/2022 at 8:50 AM, review of progress notes revealed social work (SW) notes, dated 7/21/2021 5:09 PM, with the following excerpt: This SW met with resident at bedside after learning about the elopement risk that took place earlier in the day . Residents may be experiencing some cognitive decline and more safety precautions put in place. On 7/12/2022 at 9:55 AM, review of the HHGW (Hebrew Home Greater Washington) Mental Health team notes written on 7/29/2021 under Recommendations indicated: Pt's explanation of the elopement incident on 7/21 was consistent with reports s/he provided to other individuals. S/He insists s/he acted wisely by seeking help/ride from a policeman. S/He voiced frustration re: prolonged pandemic isolation in LTC. Review of psychiatric progress notes dated 10/4/2021: Resident was seen by psychogeriatric services for evaluation post elopement.S/He verbalized feeling angry and frustrated being in thei facility and unable to do activities and exercises. S/He was fixated about wanting to leave the place. Discussed about her/his safety, s/he verbalized understanding and agreed to not leave the facility in the future without asking staff and supervision. Treatment Plan/Recommendations: Recommended to increase [MEDICATION(S)] 750 mg daily for mood. Recommended to transfer to locked dementia unit for patient safety when bed available. Continue to support and encourage. Continue to monitor for her/his behaviors. On 7/12/2022 at 10:40 AM, during an interview with the Director of Nursing (DON), she stated that, on admission, Resident #2 was not at risk for elopement, s/he was alert and oriented and later became the President of the Resident Council. The DON further stated that Resident #2 usually went outside to sit or take a walk and usually returned without any incident until 7/21/2021 when s/he went too far and sought help from a local police officer to return to the facility. When asked what the policy was for residents who wanted to go outside of the building, the DON stated that residents that were alert and oriented did not need to sign out prior to going outside to sit or take a walk. But if leaving the facility to go to the store, they were required to notify staff and sign themselves out. Those that were at risk for elopement had the wander guard bracelet that would set off the alarm if they attempted to leave the building. Their photos were also displayed at the front desk for receptionist staff to monitor. Per the DON, Resident #2 was not placed on the elopement list after 7/21/2021, but staff were monitoring her/his whereabouts. When asked what safety measures were put in place after the incident of 7/21/2021, the DON stated that the facility staff did not really consider it to be an elopement. They were trying to figure out if the resident just got lost during her/his walk, or if s/he went out to smoke, as the facility was a smoke free campus. However, the DON stated that they did many things to make the resident comfortable after the incident of 7/21/2021: staff tried to place a wander guard bracelet on the resident, but s/he refused to wear it. They got her/him a nicotine patch and s/he did okay with it. The DON further stated that, after monitoring the resident for about a month, they felt he/she did not need to be monitored. They (DON and Administrator) had a discussion with the resident, and s/he promised not to leave the unit without telling the staff. But after the second incident on 10/3/2021, as per the DON, Resident #2 was placed on 1:1 monitoring supervised by a Private Duty Aide (PDA) for almost a month. The resident was added to the list of residents identified to be at risk for elopement posted at the front desk. Resident #2 was given a phone to facilitate communication with staff. Resident #2 signed a Behavior Contract on 10/7/2021 agreeing to only leave her/his unit with a companion among other things. S/He was also given the option to either have the wander guard bracelet put on her/him or be transferred to a locked unit in the facility. Resident #2 chose to be transferred to a locked unit where s/he remained until s/he was transferred to another facility where they would be able to smoke. On 7/15/2022 at 12:02 PM, further review of Resident #2's clinical records revealed that while the elopement risk assessment done on 6/28/2021 resulted in an elopement risk score of one (1), a subsequent re-assessment completed on 7/21/2021 using the same tool, resulted in Resident #2 receiving a score of one (1), low risk for elopement. The follow-up assessment did not answer yes for residents cognitively impaired and/or has poor decision-making capability (1 point) and made statements about going home (1 point). This resulted in the resident receiving a score of 1 instead of 2-3 (moderate risk for elopement) and thereby placing Resident #2 at a low risk for elopement. Thus, no elopement risk plan was put in place following the incident on 7/21/2021. On 10/3/2021, 10/28/2021, and 1/20/2022, the resident had an elopement risk score of 4 (high risk) with 1:1 supervision as the elopement risk plan. A corrective action plan was developed and started on 10/3/2021: 1. Staff to monitor Resident whereabouts every 15 minutes and report changes and to document findings in the progress notes 2. PDA (Private Duty Aide) to provide 1:1 supervision to monitor residents' whereabouts on the unit and accompany her/him off the unit for a walk in front of the building and the garden as needed. 3. Alert the front desk of Resident ability to leave the building unannounced 4. Behavioral Health Social Worker to visit Resident during the week to assess risk of elopement, feelings of confinement and discuss Resident's interests on that day's activities 5. Education provided for unit staff and PDA on Resident's plan of care and on de-escalation techniques. Completed 10/11/2021 6. Education provided to front desk staff on how to deal with Resident when s/he comes to the front and wants to go out. Completed on 10/10/2021 7. Staff to continue monitoring the Resident to ensure s/he does not leave the unit without notice 8. Remind Resident to notify the staff whenever s/he feels like leaving the unit for a walk or to sit outside. Behavior Contract signed on 10/7/2021. 9. Assess Resident's ability to use a communication device (telephone) to contact the unit or the facility should s/he leave the premises and was unable to find her/his way back 10. Clinical Team manager CTM) to periodically discuss her/his preferred times to leave the unit for a walk or get fresh air 11. Psychological evaluation by a Licensed Psychologist. Completed on 10/4/2021 12. Interdisciplinary Team to have a discussion with Resident to have idea of places s/he leaves the facility to go to and discuss possible landmarks that will help her/him find their way back safely 13. Staff vigilance to ensure there are no smoking materials in Resident's room 14. Nicotine patch ordered to facilitate Resident smoking cessation. 15. Resident's care plan was updated on 10/3/2021 to state that the Resident enjoys being outside taking long walks. S/He does not like to notify staff when s/he wants to walk outside of the facility. Due to her/his cognitive deficits related to [CONDITION(S)], her/his safety is at risk when s/he leaves the facility unsupervised. Recent episode occurred on 10/3/2021. Interventions included: Alert the front desk that Resident should not leave the building unsupervised. Arrange for a secured unit, arrange to assist Resident off the unit if the attempt to leave the unit seemed to be Resident's need for some fresh air. 16. Elopement in-service provided to staff and completed on 10/21/2021. From 7/8/2022 - 7/15/2022, the facility's action plan and implementation of interventions were reviewed. Interviews with multiple staff, review of facility documentation including education, policies and procedures on safety checks and elopement, as well as observation of the main lobby doors and the wander guard system, and staff practices confirmed that the above interventions were implemented by the facility.

Based on surveyor review of clinical records and staff interview during the investigation of facility reported incident MD 889, it was determined that the facility staff failed to use the proper technique when transferring a resident using a mechanical lift. This finding was evident for 1 of 5 residents (#10) reviewed for injuries of unknown origin during the complaint survey and resulted in actual harm related to Resident #10. The findings include: On 9-12-19, review of the clinical record for Resident #10 revealed the resident had a [DIAGNOSES REDACTED]. Further review of the clinical record revealed that, during care on 07-14-19 at approximately 1:15AM, a GNA observed Resident #10 with discoloration and blisters on the right lower extremity and severe pain with range of motion. This was reported to the charge nurse who assessed the resident as having expansive discoloration and pain with range of motion, and notified the physician of the change in Resident #10's condition. An x-ray was ordered with the results revealing fractures of two different bones in the right lower leg. On 07-14-19 at 10:46 AM, Resident #10 was sent to the emergency department as a result of the fracture, however the authorized decision maker decided against surgery for [REDACTED]. An investigation into the cause of the fracture was initiated by the Director of Nursing on 07-14-19. The investigation revealed that the 3-11 shift GNA (Staff #5) who was assigned to resident #10 on 07-13-19 admitted that, although the care plan directed facility staff to transfer the resident with a mechanical lift and two caregivers at all times, on 07-13-19, the GNA transferred the resident without assistance from a second staff member. GNA #5 stated, the resident was not that heavy and she decided not to enlist the assistance of a second GNA to transfer the resident from the chair back into the bed. As a result, no one was present to guide Resident #10's lower extremities during transfer. Further review of the investigation revealed that GNA#5 demonstrated the technique she used to transfer Resident #10 in the mechanical lift to the Director of Nursing, and during the demonstration, the Director of Nursing noted that the absence of the second GNA to secure the lower extremities allowed Resident #10's legs to dangle freely during the course of the transfer. Upon interview, the Director of Nursing's investigation into the incident determined that Resident #10's right lower extremity, may have bumped into the metal stem of the mechanical lift during improper transfer of the resident by one caregiver instead of the required two, resulting in the two bones of the right lower leg being fractured

Based on surveyor review of clinical and administrative records and staff interview, it was determined that the facility failed to maintain a safe environment for resident #1 who was severely cognitively impaired and had a history of [REDACTED]. This deficient practice placed the resident at risk for elopement and serious harm. This finding was evident for 1 of 9 residents reviewed during a complaint survey and was identified during the investigation of facility reported incident #MD 606. Review of the facility's plan of correction implemented after the facility gained knowledge of the incident resulted in the deficiency being cited as past non-compliance. The findings include: On 07-11-18, surveyor review of the clinical record for resident #1 revealed a social service note written on 01-08-18 that documented the resident was packing his/her clothing to leave the facility. The resident told staff he/she wanted assistance to take the clothes to the car in the parking lot. The resident was reminded he/she did not have a car in the parking lot. Further review of the clinical record revealed a monthly summary note, written on 01-09-18, that documented the resident was alert and oriented to place and person. Forgetful and requires constant reminders from staff. Confused and requires redirection from staff The note continues, resident #1 Ambulates independently to and from locations on and off the unit. In addition, the note documented that the resident Wanders on the unit, requires monitoring to prevent injury to self and others and also from unplanned exit off the unit. Surveyor review of the care plans revealed a care plan that was initiated on 01-18-2018 that stated resident #1 exhibits wandering behavior, mostly to the adjacent unit, related to: cognitive impairment, mood. The goal of the care plan was resident will wander only within specified boundaries. The two listed interventions included, Allow the resident to wander on units 2 East and 2 South and Resident exhibits periods of removing clothes and personal items from dresser and closet and will request staff for assistance to take these items to her car in the parking lot; gently remind resident she/he does not have a car in the parking lot and assist resident in putting the clothes and personal items back in the dresser and closet. However, these interventions did not address any monitoring or supervision of the resident's wandering or the risk of elopement. Further review of the clinical record for resident #1 revealed another monthly summary note written on 03-09-18 that documented the resident was alert and oriented to place and person. Forgetful and requires constant reminders from staff. Confused and requires redirection from staff and stated resident #1 Uses the wheelchair and can self propel. In addition, the note documented that the resident Wanders on the unit, requires monitoring to prevent injury to self and others and also from unplanned exit off the unit. Review of a nurse's note, written on 02-03-18, revealed that resident #1 had packed his/her belongings and wanted to go home. Surveyor review of a neuro-cognitive report, dated 03-15-18, revealed that resident #1 had significantly declined cognitively and recently he/she has become fixated on 'going home'. In addition, the report documented that resident #1's cognitive functioning fell within the severe impairment range. On 04-08-18, an elopement risk form was completed for resident #1. The first question, is the resident physically able to leave the building on their own? was answered no so the rest of the assessment was not completed. However, the question was answered incorrectly. If the question had been answered yes and the rest of the assessment completed, resident #1 would have been identified as a high risk for elopement and staff would have been prompted to initiate elopement care plan and place wander guard in order to address the risk of elopement. A wander guard system is an alarm system used to alert staff if a resident who has been determined at risk for elopement is trying to leave the facility or wander into a restricted area. A transmitter is placed on the at-risk resident (typically on a band around the wrist or the ankle) and when the resident approaches the door way or area equipped with a wander guard sensor, an alarm sounds to notify staff. Review of a social service dated 04-10-18 revealed that resident #1 had placed all of her clothes on the top of the recliner and told staff he/she was going home. Further review of the clinical record revealed a Nurse Practitioner note written on 05-24-18 which documented that staff reported resident #1 has decreased his/her tobacco use; the facility is a non-smoking campus and he/she sometimes cannot find his/her way back to the facility. On 07-11-18 at 1:30 PM, during an interview by the surveyor, the Nurse Practitioner clarified that he/she had spoken to the nurse regarding resident #1 on 05-24-18, and the nurse had said that the resident was no longer going out to smoke at night because the resident could not find his/her way back upstairs. In addition, a nurse practitioner's note, written on 06-21-18, documented that resident #1 was forgetful and needs more redirection, sometimes having trouble finding her/his room. However, despite resident #1 having a more difficult time finding his/her way around, there was no reassessment of the wandering behavior or the risk for elopement. Surveyor review of the facility reported incident revealed that, on 07-02-18, resident #1 was not able to be located during change of shift report around 3:30 PM. The staff began searching nearby units where the resident would normally go. At 3:50 PM, the facility was notified by a police officer that the resident had been found in his/her wheelchair at the intersection of a six-lane main road and two lane side street (the temperature on 07-02-18 ranged between 2-4 PM was around 97 degrees F). The police officer had the resident transported to the hospital because the resident looked tired and dehydrated. Upon reviewing the front door camera, the facility discovered that the resident walked out the front door pushing a wheelchair at 1:50 PM. There was a 2-hour lapse between the time the resident left the facility and the police notification that he/she had found the resident. Surveyor review of the hospital history and physical revealed that Pt was found by a police officer sitting in his/her wheelchair on the intersection of Rockville Pike. Police reports he/she saw pt sitting in a wheelchair and thought he/she was waiting for the bus. He/she then drove past him/her 45 minutes later and he/she hadn't moved. Further review of the hospital history and physical revealed that, upon arrival to the emergency room , resident #1's blood pressure was low and pulse and temperature were increased. In addition, the resident was drowsy but would wake up to name calling and start moaning. The resident was diagnosed with [REDACTED]. On 07-11-18 at 3:30 PM, surveyor interview with the Director of Nursing provided no additional information. Immediate actions taken by the facility on 07-02-18 included: A quick census was conducted and all the residents on the units were accounted for. A photo collage of residents that are able to leave their units independently to sit outside in front of the buildings was posted at the front desk. The collage was also circulated to all units for staff to familiarize themselves with the residents that are identified as safe to leave the unit and sit independently in front of the building. (The front desks are staffed 24/7 and the doors are locked between the hours of 8 PM and 6 AM) On 07-03-18, the clinical team managers completed elopement risk assessments for all residents that were identified as capable of sitting outside without a staff member or other companion. On 07-05-18, The Director of Nursing provided clarification and training to the nurse clinical team managers on how to properly complete the elopement risk assessment form. The elopement risk assessment will be completed on admission, quarterly, and with significant change in status, and the resident care plans will be updated accordingly. All GNAs (geriatric nursing assistants) will monitor the location of their residents every two hours and account and sign for their residents at the end of their shift. If anyone is missing they must be accounted for. The GNA point of care documentation has been updated to reflect this change. The facility is currently installing outside cameras that will allow for visual monitoring of residents that are sitting in front of the buildings. The Director of Nursing and the Assistant Director of Nursing will submit and review the audits with the QAPI (quality assurance) committee every month for three months or until a complete compliance is achieved as determined by the committee. The facility's compliance date was 07-05-18.

Based on surveyor observation, review of the clinical record and staff interviews, it was determined that the facility staff failed to prevent a resident from sustaining a fall with a resulting injury. This finding was evident in 1 of 15 residents selected for review. (#7). This finding was identified during the investigation of facility reported incident #MD 119. Review of the facility's plan of correction implemented immediately after the incident resulted in the citation being cited as past non-compliance. The findings include: On 08-30-17, a review of the closed clinical record and facility reported incident revealed that resident #7 sustained a fall from a transfer lift - (which is described as a Sera Stand and Lift machine) on 07-31-17. The transfer was initiated by a private duty sitter (who was told not to transfer the resident without the assistance of the staff) on the same evening that the transfer was initiated. During the transfer, it was described that, as the resident started to fall, the sitter called for help. When staff arrived, it was noted that the resident was suspended by the sling in the standing position, and staff completely lowered the resident to the floor before transferring the resident to bed with the help of three staff members. Once in bed, based on the facility report, the resident complained of pain to the right shoulder. The resident was medicated for pain, the physician was notified and an x-ray of the shoulder was taken. The x-ray revealed a fracture of the right humeral neck (upper arm bone near top, just under the shoulder joint). Record review of notes and care plans revealed that resident #7 was to be transferred by a different type of lift with 2 persons - called an Arjo lift. This is a type of lift using a sling under the resident's buttocks and up the back. The resident is then transferred, without weight bearing, from the bed to the chair or reverse. This type of mechanical device requires two people to safely execute the transfer, one to operate the lift, and the other to guide the resident's torso safely. This was a change in transfer devices based on a decline in the resident's condition. On 08-30-17, interview revealed that staff had specifically instructed the private duty sitter not to transfer resident #7 out of bed until staff were present to assist. The sitter had told the charge nurse that he/she wanted to take the resident for a shower. Based on interview of staff, the sitter had been taking care of the resident prior to admission, and had cared for the resident in the facility for at least 3 years. Based on staff interviews, staff reviewed the duties and restrictions of the private duty sitter position when the resident was admitted , and they met daily with the sitters to give and obtain report. On 08-30-17, interview with the charge nurse who worked the evening of 07-31-17 with resident #7, revealed that she/he specifically gave those directions prior to the sitter performing the transfer. On 08-30-17 at 11:15 AM, interview with the director of nursing (DON) confirmed that the administrative report accurately depicted the events resulting in resident #7's fall on 07-31-17 and follow up action. The DON stated that the sitter did not follow the facility's protocol for privately hired sitters, and did not follow the direction of the charge nurse to obtain staff assistance. The DON also shared that the private duty sitter was not a licensed caregiver by the (NAME)land Board of Nursing. On 08-31-17 at 9:50 AM, the surveyor observed an Arjo lift transfer of resident #7, between the bed and wheelchair, with two staff carrying out the transfer safely. Interview of the two geriatric nursing assistants (GNAs) revealed that they had been trained in the use of mechanical lifts. One of the GNAs demonstrated the use of the stand up lift that had been used by the sitter on 7-31-17. On 09-05-17, review of facility documentation revealed that, on 07-31-17, the evening shift supervisor was notified of the incident. That supervisor notified the EAGLE team of the incident. The Eagle team consisted of the CEO, Administrator, DON, Director of Quality Improvement, Medical Director, Attending Physician, Director of Social Work, and Unit Manager. On 08-31-17 and 09-05-17, further review of administrative records, and interview with the DON, revealed that the facility identified and implemented immediate corrective action on 08-01-17. The corrective action included: a. On 08-01-17, the DON interviewed the private duty sitter of resident #7 to determine why and how resident #7 sustained the fracture At that time, the DON reported that the Performance Improvement Manager (quality assurance), the Assistant DON (ADON), and Medical Director were present when meeting with the private duty sitter. (signed form by sitter provided to surveyor) b. On 08-01-17, the above administrative staff met with the private duty sitter of resident #7, and he/she reviewed the facility policy on the role of the private duty sitter as a companion to provide minimal care. The services excluded completed bed bath, showers, and transfers . c. On 08-01-17, the DON and ADON had a discussion with the unit managers and evening shift supervisors regarding the need to reinforce the private duty aide policy with residents and family members. d. On 08-02-17, the Unit manager, Risk manager, DON and Director of Improvement met with the entire multidisciplinary team representing all departments, in a standup meeting, to discuss the incident. e. On 08-02-17, the nurse manager had a discussion with the resident's family about their plans for the sitter in anticipation of resident #7's return from the hospital. The family elected to have the sitter comtinue as a companion to resident #7. f. On 08-08-17, the DON obtained a list of all private duty aides (PDA) and met with the PDAs in both buildings and reviewed the policies and procedures of their duties, with emphasis on what they were allowed and not allowed to do. g. On 08-9-17, the DON revised the facility policy to accommodate those that felt the PDA could provide more than companionship. h. On 08-17-17, the DON met with all nurse managers, and all shift supervisors to discuss the impact of the incident and reviewed the facility revised policy. i. On 08-18-17. nurse managers met with all the respective residents (and/or their representatives) to reinforce the facility policy. j. Inservicing on revised policy (and increased vigilance to prevent reoccurrence), was implemented with completion dates for education of all staff on 09-15-17 (65% compliance) and 09-30-17 (95% compliance). k. Ongoing - nurse managers to review the policy with PDAs and residents or representative upon admission and document in the records. l. Ongoing - nurse managers to conduct a weekly meeting with the PDAs to ensure compliance with the policy. The DON provided evidence of the reviews by providing the time line of completion, and evidence of the meeting with the sitter and private duty aides sign in sheet, dated 08-08-17. The meeting with the nurse managers was completed on 08-17-17. Based on interview with the DON, and unit manager, there have been no other incidents related to sitters and PDAs. On 09-05-17 at 10:57 AM, interview with the Director of Quality and Corporate Compliance, (who was not present when this incident occurred) revealed that, after an incident occurs, the incident is brought to a multidisciplinary stand up meeting of about 30 disciplines who review each case. This meeting occurs every Monday, Wednesday and Friday - (described as in d above on 08-02-17). Every month, the Quality Assurance (QA) committee meets to review cases from the month before. The QA full committee had met to discuss the number of fractures and injuries in the facility as a whole and to look at the root cause analysis and develop a plan of action on 08-29-17. The August data will be reviewed at a full meeting in September.