Every finding on record at Meadow Park Rehabilitation and Healthcare Center

Based on record reviews, interviews, and review of facility policy, it was determined that the facility failed to: ensure that non pharmacological interventions were implemented and documented prior to the administration of as needed (PRN) narcotic medications, and clarify if pain levels should determine which pain medication should be administered. This is evident for 4 Residents ( Residents #3, #131, #81 and #99) of 6 resident records reviewed for unnecessary medication and pain management during the annual survey. The Findings Include: Non-pharmacological interventions are identified as an alternative method of treatment for a medical concern without the use of medication. This could include physical, psychological, and lifestyle interventions designed to reduce pain and improve quality of life. The CDC's 2022 Clinical Practice Guideline for Prescribing Opioids emphasizes non-pharmacological, non-opioid therapies as the first line of treatment for subacute and chronic pain. 1) On 7/20/2026 at 8:04 AM, during the screening process of the survey, Resident #131 stated that his/her pain medication had been changed from every 6 hours to every 12 hours, and the pain in his/her bilateral hip is very severe. On 7/21/2026 at 8:47 AM, A review of Resident #131's medical record noted that resident was admitted on [DATE] with diagnoses including bilateral artificial hip joints, unspecified fracture of the femur bone with routine healing, osteoarthritis, and hypertension. On 7/21/2026 at 12:48 PM, a review of the physician's order dated 7/21/2026 directed to give Oxycodone 5 mg by mouth every 6 hours as needed (PRN) for pain for 30 days. A review of the Medication Administration Record revealed that Resident #131 had been administered the PRN medication a few times since admission. Further review of the medical records on 7/21/2026 at 12:57 PM, noted that the nursing progress notes and the Treatment Administration Record (TAR) lacked documentation of any non pharmacological interventions attempted or offered prior to medication administration; Furthermore, the care plan initiated on 7/18/2026 for have chronic pain and/or potential for pain related to Arthritis lacked the interventions to use nonpharmacological measures prior to the administration of PRN narcotics. On 7/22/2026 at 9:00 AM, during an Interview, the Director Of Nursing (DON) stated that the facility's policy is that resident who are taking PRN medications should have non-pharmacological interventions in their records so that residents can be monitored. The DON was made aware that Resident #131 did not have any documentation of nonpharmacological interventions and that it's a concern. The DON stated that some residents have it in their records and some don't, and the goal is to ensure that residents taking a PRN narcotic will have nonpharmacological interventions added to their records. 2) On 07/20/2026 at 2:08 PM, a review of Resident #3's current physician orders revealed the following active PRN (as-needed) narcotic orders for pain control: Oxycodone HCl Oral Tablet 5 MG (Oxycodone HCl) Give 0.5 tablet by mouth every 4 hours as needed for pain, pain scale of 6-10 -Start Date- 05/08/2026 at 10:00 PM. On 76/20/2026 at 3:19 PM, a review of Resident #3's Medication Administration Record (MAR) revealed that oxycodone 5mg was administered 4 times in May 2026 and Oxycodone 5mg was administered 2 times in June 2026. On 07/20/2026 at 3:22 PM, a review of Resident #3's medical records revealed that the pain and/or potential for pain r/t Arthritis care plan was initiated on 04/17/2026 encourage me to try non-pharmacological interventions for pain relief as applicable e.g. positioning, relaxation therapy, bathing, heat and cold application, muscle stimulation, ultrasound. On 07/20/2026 at approximately 3:30 PM, a review of Resident #3's medication and/or treatment administration record revealed no documented evidence to support that the facility implemented non-pharmacological interventions prior to the administration of opioids. On 07/22/2026 at 8:47 AM, the Director of Nursing (DON) was asked how the facility documents the non-pharmacological interventions and she stated she will need to double check where it is documented. On 07/23/2026 9:40 AM, in an interview with the DON, she explained that non-pharmacological interventions were provided before they provide PRN opioid medication, the nurse can initiate non-pharm interventions. The expectation was that if a resident was receiving any PRN opioids, then the non-pharmacological interventions should be documented. Non-pharmacological intervention such as music, distraction etc. should be used and documented in the resident's medical records and she confirmed that the non-pharmacological interventions were not documented for Resident #3. 3) A review of Resident #81's clinical record revealed the resident's physician wrote on order for the resident to be administered Tylenol 350 mg two tablets every six hours for mild pain and morphine sulfate solution 20mg/ml give 0.25 ml by mouth every 4 hours as needed for pain. However, without clearer instructions the nursing staff could administer both medications for mild pain because the morphine did not include parameters. On 9/21/23, nursing staff were ordered to offer non-pharmacological interventions prior to administering pain medications. A review of the resident's Medication Administration Record (MAR)'s for May, June, and July 2026 revealed not one member of the nursing staff documented that they used non-pharmacological interventions. 4) A review of Resident #99's July MAR revealed that on 7/22/26 the nursing staff were ordered to document that they offered the resident non-pharmacological interventions prior to administering pain medications, but the nursing staff did not document any such attempt.

Based on resident interview, staff interview, and a review of the Payroll Based Journal (PBJ) it was determined that the facility administration failed to staff the facility at sufficient levels. The findings include:A review of the PBJ on 7/20/26 revealed that the facility self-reported low staffing on the weekends From January to March. A member of the survey team interviewed the Dietary Manager on 7/19/26 at 7:51 AM. The Dietary Manager was asked what time do the food carts get sent to the dining rooms. He responded that the dining rooms were not open secondary to the facility not having enough nursing staff to supervise the residents while they ate. He added that they have been closed for 4-5 months. Resident #115, who had a Brief Interview of Mental Status (BIMS) score of 11 which indicates moderately impaired cognition, was interviewed on 07/19/2026 at 10:31 AM. The resident was asked if the facility has enough staff and they responded that the facility was short staffed, especially at night.A member of the survey team interviewed Resident #132, BIMS of 15 which indicates an intact cognition, on 7/19/26 at 11:05 AM. The resident said they laid awkwardly in their bed from 8:00 PM to 5:00 AM and used the call light but no one came. The Resident further stated that they did not come the day before either. Resident #110 was interviewed on 7/19/26 at 12:26 PM. The resident was asked if they think the facility is short staffed and the resident responded that they are short staffed and sometimes residents have to wait hours for staff to respond. Resident #55 was interviewed by a team member on 7/20/26 at 9:54 AM. The resident stated that nursing staff don't attend to the call light when the resident uses it and sometimes they don't come at all. The Dietary Manager was interviewed on 7/21/26 at 7:50 AM. He was asked about the closed dining room. He said the dining room was closed due to reduction in staff and has been closed for 4 to 5 months. Resident Council was informed and notices were sent to all of the residents.Resident #117 was interviewed on 7/21/26 at 1:00 PM. The resident was asked if they normally eat lunch and dinner in the dining room. The resident said we used to eat in the dining room but the facility closed it for some reason, but I forgot what it was but something happened and it should be over soon. A member of the survey team interviewed the former Resident Council President on 7/21/26 at 1:05 PM. The surveyor asked if they had any staff issues. Resident #31, who had a BIMS of 15, replied that they had to wait a long time for staff to respond to call lights being turned on by residents. The resident also complained of not being able to eat in the dining room.The facility administrative staff were informed of the staffing concerns on 7/23/26 prior to the survey team exiting the building.

Based on a review of Beneficiary Protection Notification, residents' medical records and staff interviews, it was determined that the facility failed to timely provide notification to a resident or their representative (RP) regarding their rights related to discharge from Medicare. This affected 2 of 3 residents (Residents #8 and #58) reviewed for liability notices during the annual survey.The findings include:Residents enrolled in Medicare Part A have specific rights and protections regarding financial liability and appeals. These rights are communicated through written notices provided by facilities to residents who are being discharged from Medicare services while still having benefit days available.Advance Beneficiary Notice (ABN): A written notice provided prior to delivering items or services, informing the resident that Medicare may deny payment. The ABN allows the resident to accept or refuse the service and protects them from unexpected financial liability.Notice of Medicare Non-Coverage (NOMNC): A notice required to be issued at least two calendar days prior to the last covered day of Medicare services.During the entrance conference on 7/19/26 at approximately 9:00 AM, the surveyor requested completion of the form titled Beneficiary Notice - Residents discharged Within the Last Six Months.On 7/22/26, the facility submitted the requested Beneficiary Notice form; however, it contained inaccurate information.On 7/23/26 at 8:10 AM, the surveyor reviewed a revised Beneficiary Notice form. The form listed Resident #68 as having been discharged to remained in facility. However, a review of medical records indicated that Resident #68 had resided in the facility continuously since 2021 under Medicaid coverage. The surveyor informed the Nursing Home Administrator (NHA) that the form was inaccurate.On 7/23/26 at 11:26 AM, the NHA provided a third revised Beneficiary Notice form. This form remained inaccurate, as none of the eight pages listed any resident names under the section remained in facility. The surveyor informed the NHA that the facility failed to provide accurate information to support the survey process.On 7/23/26 at 12:20 PM, the surveyor reviewed the facility's electronic medical records (EMR) and identified residents who should have been listed as remained in facility, including Residents #8 and #58.On 7/23/26 at 1:23 PM, the facility provided documentation for Residents #8 and #58. A review revealed the following:-Resident #8: The last day of Medicare Part A coverage was 5/06/26; however, the ABN was signed on 5/07/26. Additionally, there was no record of a NOMNC being issued.-Resident #58: The last day of Medicare Part A coverage was 6/24/26; however, the ABN was signed on 6/25/26 and there was no record of a NOMNC being issued. Additionally, the payer resource changed on 6/25/26 as private pay, and on 7/01/26 as Medicaid Pending.During an interview on 7/23/26 at 1:32 PM, the Social Worker stated that facility staff typically provide ABNs to residents or RPs at least two days prior to the end of Medicare coverage. Upon reviewing the medical records for Residents #8 and #58 alongside the surveyor, the Social Worker confirmed that the two ABNs were not completed in a timely manner.During the exit conference on 7/23/26 at approximately 2:00 PM, these concerns were presented to facility leadership, who validated the findings.

Based on review of complaint #3065681, record review, and interview, it was determined that the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's diagnosis of anemia and the associated risk for complications. This was evident for 1 (Resident #125) of 4 residents reviewed for care planning during the recertification survey.The findings include:A comprehensive care plan is an individualized plan of care that identifies a resident's specific needs, establishes measurable goals, and outlines interventions necessary to attain or maintain the resident's highest practicable physical, mental, and psychological well-being.Anemia is a condition in which the body does not have enough healthy red blood cells or hemoglobin to adequately transport oxygen to the body tissues. According to the Mayo Clinic, the normal adult reference range for red blood cells (RBC) is approximately 4.35 to 5.65 million cells/mcL for men and 3.92 to 5.13 million cells/mcL for women, while hemoglobin (Hgb) ranges from 13.2 to 16.6 g/dL for men and 11.6 to 15.0 g/dL for women.On 7/22/2026 at 1:00 PM, a review of Resident #125's medical record revealed diagnoses that included anemia.The medical record further revealed a physician's order dated 4/28/2026 for Ferrous Sulfate 325 mg (65 mg elemental iron), give 1 tablet by mouth daily for anemia.Review of the laboratory results revealed a progressive decline in Resident #125's hematologic status, including:-6/1/2026- RBC 3.01 x10E6/uL and Hgb of 7.9 g/dL-6/25/2026- RBC 2.34.01 x10E6/uL and Hgb of 6.1 g/Dl.The record further revealed that, due to the severity of the anemia, a physician's order dated 6/30/26 directed Resident #125 to receive a blood transfusion on 7/1/2026.Despite the resident's diagnosis of anemia, abnormal laboratory values, ongoing iron therapy, and subsequent need for a blood transfusion, review of the comprehensive care plan failed to identify anemia as a care plan focus and failed to include individualized goals or interventions to monitor, manage, or evaluate the resident's condition.On 7/23/26 at 9:37 AM, during an interview, the Director of Nursing (DON) stated that upon admission, the nursing supervisor initiated the residents' care plans, and the Nurse Manager updated them the following day. The DON further stated that care plans were continuously reviewed, revised, and resolved as residents' condition changed.On 7/23/26 at 12:01 PM, the DON confirmed that Resident #125 did not have a care plan addressing anemia. The surveyor notified the DON of the concern.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure Interdisciplinary Team (IDT) care plan meetings were conducted and documented in conjunction with quarterly Minimum Data Set (MDS) assessments. This affected three (Residents #37, #99 and #9) of eight residents reviewed for care planning during the annual survey. The findings include: Comprehensive care plans must be developed within seven days of the completion of an admission assessment and updated following each quarterly MDS assessment, or as a resident's condition changes. The care plan must be reviewed and revised by an interdisciplinary team—which includes the attending physician, a registered nurse, a nursing assistant, a dietary staff member, the resident, and/or the resident's representative—with each meeting formally documented in the medical record. 1) On 7/22/26 at 7:59 AM, a review of Resident #37's medical record revealed MDS assessments completed on 8/01/25, 11/01/25, 2/21/26, and 5/02/26. However, there was no documentation in the record to evidence that IDT care plan meetings were held following the February 2026 and May 2026 MDS assessments. 2) On 7/22/26 at 9:14 AM, a review of Resident #9's medical record revealed MDS assessments conducted on 8/24/25, 10/02/25, 1/02/26, 4/04/26, and 7/05/26. Care plan meetings were documented on 8/28/25, 10/08/25, 4/01/26, and 7/01/26. There was no documentation to support an IDT care plan meeting was held following the 1/02/26 MDS assessment, and the care plan meetings recorded in April and July 2026 were held prior to the completion of the corresponding MDS assessments. On 7/22/26 at 7:38 AM, during an interview with Social Services Director/Worker #26, she stated that care plan meetings should be linked to the completion of the MDS assessment, adding: I try to complete the care plan meeting within seven days after the MDS assessment. Upon reviewing the care plan meeting records for Residents #37 and #9 with the surveyor, Social Worker #26 confirmed and validated that the care plan meeting dates were not aligned with the completed MDS assessment dates. 3) A review of Resident #99's clinical record on 7/23/26 revealed the resident had quarterly care plan meetings on 11/6/25, 3/18/26, and 5/7/26. A quarterly care plan meeting was to be held every 90 days which meant the Interdisciplinary Team (IDT) should have met on 2/6/26 not on 3/18/26. The Director of Nursing was interviewed on 7/23/26 at 12:03 PM. This surveyor informed her of the resident's re-admission date, the dates of the care plan meetings, and explained when the care plan meetings should have been held if the facility adhered to the every 90 day requirement. She said she understood that the care plan meeting should have been held in February 2026 not March.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure that residents received necessary monitoring and care to promote their well-being. This was evidenced of one (Resident #105) of eight residents reviewed during the survey.The findings include:During an initial screening on 7/19/26 at approximately 9:00 AM, Resident #105 was observed with a midline catheter inserted in the right upper forearm. The resident stated, I don't know why I need this. Nurses flush this one every shift, but nothing has been infusing for a while.On 7/22/26 at 11:12 AM, a review of Resident #105's medical record revealed physician orders dated 4/27/26 to flush the midline catheter and perform dressing changes. The record further showed orders for intravenous (IV) Ceftriaxone (an antibiotic) once daily for leukocytosis from 6/02/26 to 6/05/26 and IV Dextrose solution for hypernatremia from 6/02/26 to 6/05/26. However, there were no active IV infusion orders after 6/05/26.On 7/23/26 at 9:29 AM, during an interview with the Director of Nursing (DON), the DON stated that facility staff routinely review resident IV access and attempt to remove lines that are no longer in use, though sometimes the provider wants to keep it. When the surveyor asked if the facility had documentation regarding IV site evaluations or provider orders to maintain access for Resident #105, the DON confirmed there was no documentation indicating the provider requested to retain the line. When the surveyor expressed concern that Resident #105 maintained unnecessary IV access for over 40 days without an active order, the DON acknowledged and validated the findings.

Based on record reviews and staff interviews, it was determined that the facility failed to timely address and communicate significant weight changes. This deficiency was evident for three (Residents #5, #7 and #105) of six residents reviewed for nutrition during the annual survey. The findings include: 1) On 7/19/26 at 9:41 AM, during a screening interview, Resident #105 reported that he/she was experiencing weight loss. On 7/20/26 at 7:36 AM, a review of Resident #105's medical record revealed a documented weight of 151.8 lbs on 7/02/26, representing an 18.39% loss (34.2 lbs) from 186 lbs on 6/03/26. The subsequent weight was documented as 148.8 lbs on 7/08/26. Further review of the medical record revealed that a dietitian authored nutrition notes on 6/25/26 and 7/09/26. However, there was no documentation regarding the severe weight loss identified on 7/02/26. The note dated 7/09/26 stated: Wt changes discussed during risk meeting today IDT/MD present. Wt loss is unfavored and unplanned, likely d/t decreased intakes and increased demand for protein/calories d/t wounds . Recommended weekly weight for closed monitoring. No further weights were documented following 7/08/26. On 7/21/26 at 12:53 PM, during a phone interview, Dietitian #7 stated that facility staff (including the provider, nurses, and dietitian) review resident weight changes during weekly risk meetings. After reviewing Resident #105's record with the surveyor, Dietitian #7 confirmed there were no records regarding the severe weight loss reported on 7/02/26. On 7/21/26 at 2:04 PM, during an interview with the Director of Nursing (DON), the DON stated that Resident #105 was followed by a psychologist regarding severe weight loss on 7/09/26. The DON acknowledged that no evaluation or intervention was provided on 7/02/26 when the initial weight change was identified. 2) On 7/19/26 at 12:21 PM, a review of Resident #5's medical record revealed a 7.12% weight gain (9.2 lbs) from 6/17/26 to 7/06/26. Further review showed a nutrition progress note authored on 6/25/26 regarding the resident's nutritional status. However, there was no additional documentation—such as a re-weight, nursing note, dietitian evaluation, or provider intervention—addressing the significant weight gain after it was recorded on 7/06/26. On 7/21/26 at 12:53 PM, during a phone interview, Dietitian #7 stated that weight changes within 30 days (5%), 90 days (7.5%), or 180 days (10%)—whether gain or loss—are considered significant or severe. She stated these changes should be discussed with the resident, responsible parties, and facility staff, and that a re-weight is expected within 24 hours of a significant change being reported. When asked if she was aware of Resident #5's weight gain and if actions were taken, Dietitian #7 stated she discussed it with the Interdisciplinary Team (IDT) and requested a re-weight via email on 7/09/26 and 7/16/26. She acknowledged that email communications are not part of Resident #5's official medical record and confirmed the facility staff had not completed the re-weight to date. 3) A review of Resident #7's clinical record on 7/22/26 at 11:00 AM revealed that staff weighed the resident on 5/18/26 and the resident weighed 108.2. The resident was weighed again on 6/1/26 and the resident weighed 110.5 pounds. On 6/8/26 staff weighed the resident and the resident weight was 130.0. This sudden increased should have caused nursing staff to do a re-weigh in case it was an accurate weight which have alerted staff of a potential issue that might not be related to consumption of food. The resident was weighed on 6/11/26 and the resident weighed 110.2. Further review revealed no progress note was written in regard to the weight on 6/8/26. It was unclear if the physician or nurse practitioner were notified. The failure of obtaining a re-weight potentially delayed treatment for a new medical issue.

Based on observation, record review, and interview, it was determined that the facility failed to ensure that the medication error rate was less than five percent during the medication observation. This was evident for 7 of 31 medications observed, resulting in a 22.58% medication error rate.The findings include:Percutaneous Endoscopic Gastrostomy (PEG) tube medication administration is the process of administering medications directly into a resident's stomach through a gastrostomy tube in accordance with physician orders.On 7/22/2026 at 8:36 AM, during the medication administration observation, Registered Nurse (RN) #15 crushed and administered the following medications orally to Resident #1, despite active physician orders directing that each medication be administered via PEG tube:1. Amlodipine Besylate 5 mg- Give 1 tablet via PEG tube once daily for Hypertension.2. Escitalopram Oxalate 10 mg- Give 1 tablet via PEG tube once daily for Depression.3. Folic Acid 1 mg- Give 1 tablet via PEG tube once daily for Supplement.4. Keppra 1000 mg (Levetiracetam)- give 1 tablet via G tube twice daily for Seizures.5. Metoprolol Tartrate 25 mg- Give 1 tablet via PEG tube twice daily for Hypertension.6. Magnesium Oxide 400 mg- Give 1 tablet via PEG tube twice daily for Supplement.7. Thiamine HCl 100 mg- Give 1 tablet via PEG tube once daily for Supplement.A review of the physician's orders at the time of medication administration revealed no order authorizing oral administration of these medications or documenting that the resident's route of medication administration had been changed from PEG tube to oral.On 7/22/2026 at 8:48 AM, the surveyor informed RN #15 of the concern. RN #15 acknowledged that the medications had been administered orally for a week and stated that he/she would contact the physician to obtain orders authorizing oral administration.On 7/22/2026 at 9:40 AM, during an interview, Licensed Practical Nurse (LPN) #18 stated that nurses were expected to verify the prescribed route of administration before administering medications and contact the physician to obtain a new order whenever a resident's route of medication administration changed.On 7/22/2026 at 10:20 AM, a subsequent review of the physician's orders revealed that the medication administration route had been changed from via PEG tube to by mouth indicating that the required orders were obtained after the medications had already been administered by the incorrect route.On 7/22/2026 at 11:51 AM, a review of the facility's Medication Administration policy revised April 2019, revealed the following:Medications are administered in accordance with prescriber orders, including any required timeframe.The individual administering the medication checks the label (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.On 7/23/2026 at 9:36 AM, the Director of Nursing (DON) was informed of the findings.

Based on record review and interviews, it was determined that the facility failed to ensure that Resident #31 was free from significant medication error. This was evident for 1 (Resident #31) of 24 resident records reviewed during the annual recertification process.The Findings Included:According to the Centers for Disease Control and Prevention (CDC), amoxicillin is a first-line penicillin-class antibiotic used to treat specific bacterial infections.On 07/22/2026 at approximately 12:00 PM, a review of Resident #31's medical records revealed that the resident was noted to have an allergy to Penicillin and sulfa antibiotics; however, a review of the resident's February 2026 Medication Administration Record (MAR) indicated that the resident received an order for amoxicillin. Record review also revealed that the resident's Penicillin allergy was documented in the resident's chart on 06/29/2022. A further review of Resident #31's MAR revealed that the resident received the first dose of amoxicillin on 2/15/2026 at 8:37 PM. The resident subsequently received a total of 6 doses of amoxicillin.On 07/22/2026 at approximately 12:05 PM in an interview with the Director of Nursing (DON), she was asked to explain how the facility addressed medication errors and she explained that if a medication error occurred they would do an assessment to ensure the resident was safe, notify the doctor, conduct Quality Assurance Performance Improvement (QAPI) review of the occurrence, conduct in-service/education to ensure the same incident does not reoccur, complete incident report, notify the resident and/or family, if applicable.On 07/22/2026 at 1:52 PM, a review of a physician's order written on: 02/15/2026 at 8:18 PM revealed Amoxicillin Oral Tablet 500 MG (Amoxicillin) give 1 tablet by mouth one time only for PNEUMONIA until 02/15/2026 23:59 and on 02/15/2026 at 8:15 PM Amoxicillin Oral Tablet 500 MG (Amoxicillin) give 1 tablet by mouth every 8 hours for PNEUMONIA until 02/20/2026 23:59.On 07/22/2026 at 2:00 PM, a review of the resident's progress notes it revealed a notification alert in the resident's electronic medical records that on 2/15/2026 8:18 PM Physician's Order Note, Note Text: The system has identified a possible drug allergy for the following order: Amoxicillin Oral Tablet 500 MG Give 1 tablet by mouth every 8 hours for PNEUMONIA until 02/20/2026 23:59; however, the medication was still administered.A further review of the resident's progress notes revealed that on 02/18/2026 at 06:43 AM, a review of a change of condition form completed by nursing revealed that: During morning rounds resident stated that he/she was having an allergic reaction to a medication, Resident stated he/she was feeling itchy all over. On assessment resident vital signs was within normal limits, no shortness of breath noted. Medical Doctor (MD) made aware, order to Discontinue penicillin, new order x1 dose Benadryl 25mg for allergic reaction and Benadryl 25mg every 6 hours PRN (as needed) for allergic reaction. Primary Care Provider responded with the following feedback: Recommendations: New order x1 dose Benadryl 25mg for allergic reaction and Benadryl 25mg every 6 hours PRN for allergic reaction.On 07/22/2026 at 2:27 PM, in an interview with MD#28, she was asked about Resident #31's allergic reaction incident on 02/15/2026 and MD#28 reported that the amoxicillin was ordered to treat a respiratory infection. She explained that she was not in front of the computer at the time she was called, so she was unable to verify the resident's allergies and she explained that the resident was fairly new to her. MD#28 was asked if she was aware that the resident had a previously documented allergy to penicillin, and she explain that she was not aware and once she was told of the allergic reaction that she ordered an immediate stop of the medication and ordered medication to treat the symptoms. She stated that she visited with the resident for several days to follow-up with the resident's status. She agreed that the incident was unfortunate and it was an oversight that should not have happened.On 07/22/2026 at 2:55 PM, in an interview with unit manager/nurse #14, she was asked to explain the incident related to Resident #31's allergic reaction and she explained that she obtained the telephone order from MD#28 for an antibiotic to treat the resident's infection. She continued to explain that after she spoke with MD#28 her biggest focus was to pull the medication because she did not want to delay the resident's treatment, so she pulled it from the Omnicell (medication storage) right away. She was asked why the resident's allergies were not discussed with the MD. When asked she stated that normally when she called the MD, they would ask the resident's allergies before ordering medications and it would prompt her to look at the resident's allergies in the medical records. She explained that she doesn't remember if the MD asked or if she informed the resident's MD of the allergies, her main goal was to get the medication to the resident as soon as possible and she did not wait for the pharmacy to approve the medication.On 07/22/2026 at 3:07 PM, in an interview with the Director of Nursing (DON), she was informed that the resident received 4 doses of amoxicillin; 5th dose was held by a nurse on 2/17/2026 dayshift; then the resident received the 6th and 7th dose. The DON was asked why the medication was held and she stated that she will investigate the reason why the 5th dose was not given. The DON later reported that the medication was not available and as a result the 5th dose was not given. On 07/22/2026 at 4:27 PM, the DON provided documentation to support that the facility initiated their plan of correction process and has implemented some interventions which included in-service training (nurse to review allergies before medication administration). However, there was no documentation suggest how the healthcare practitioner including but not limited to Physicians, Nurse Practitioners, etc. were included in the facility's corrective action. The DON was asked if there was an alert in place for the medication dispensing machine that would notify staff when they attempt to remove medications that contradicts with resident allergies and she confirmed that there was no mechanism to alert staff before removing the medication from the medication dispensing machine. The facility's plan of correction did not thoroughly address how they will prevent the issue from reoccur again.

Based on observations and interviews with residents and staff, it was determined that the facility failed to prepare and serve meals in accordance with residents' nutritional preferences and orders. This failure affected one of five resident meal tickets (Resident #105) reviewed during the annual survey.The findings included:During an initial interview with Resident #105 on 7/19/26 at 9:40 AM, the resident stated, The menu does not match the meal ticket. It happens about 50% of the time.A concurrent observation of Resident #105's meal ticket and meal tray revealed significant discrepancies. The meal ticket listed:Hot cerealFlorentine egg bakeBreakfast sausageBiscuit with jelly and margarineSkim milk, juice, and coffeeHowever, the tray provided to the resident contained only one muffin, mashed potatoes, a cup of juice, and milk. The hot cereal, Florentine egg bake, breakfast sausage, and biscuit were missing.During an interview on 7/23/26 at approximately 2:00 PM, facility leadership acknowledged the finding, stating that the served meals should match the meal ticket orders. The finding was validated by facility staff.

Based on observations, record reviews, and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. These failures occurred during the medication administration task, environmental tours of the facility laundry room, soiled utility rooms, and resident rooms during the annual survey. The findings include: According to the Centers for Disease Control and Prevention (CDC), Enhanced Barrier Precautions (EBP) involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with an MDRO (MDRO stands for multidrug-resistant organism, which refers to germs—mainly bacteria—that resist three or more families of common antibiotics), or those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Transmission-Based Precautions (e.g., Contact Precautions) are the second tier of basic infection control used in addition to Standard Precautions for patients who may be infected or colonized with specific infectious agents to prevent transmission. [CDC guideline] 1)On 7/20/26 at 10:31 AM, the Infection Preventionist (IP) submitted a list of residents on Transmission-Based Precautions (TBP) per the surveyor's request. The document listed four residents (Residents #4, #5, #12, and #57) under the title List of MDRO. On 7/20/26 at 10:45 AM, during an interview, the surveyor asked why an MDRO list was provided instead of a TBP list. The IP stated, This is the list of Contact Precautions. The facility does not have any residents under Droplet or Airborne Precautions at this time. We have those residents (Residents #4, #5, #12, and #57) for Contact, and some for Enhanced Barrier Precautions. The IP indicated Residents #4, #5, and #12 had vancomycin-resistant Enterococci (VRE), and Resident #57 had carbapenem-resistant Enterobacteriaceae (CRE). On 7/20/26 at 10:50 AM, a review of medical records revealed conflicting orders and signage: -Resident #4: Medical record contained an order for Contact and Droplet Precautions for Shingles. However, both an EBP sign and a Contact Precautions sign were posted on the resident's door. -Resident #5: Medical record contained an order for Enhanced Barrier Precautions for VRE, MRSA, and sacral wound. Because this resident shared a room with Resident #4, both EBP and Contact Precautions signs were posted on the door. -Resident #12: Medical record contained an order for Enhanced Barrier Precautions for VRE in urine. An EBP sign was posted on the room door. -Resident #57: Medical record contained an order for Enhanced Barrier Precautions for CRE. An EBP sign was posted on the room door. On 7/20/26 at 1:39 PM, during an interview, the IP stated that because Personal Protective Equipment (PPE) requirements are similar for EBP and Contact Precautions, the facility used the same door signage interchangeably. The IP confirmed that Residents #4, #5, and #12 had active orders related to VRE and Resident #57 for CRE. On 7/21/26 at 7:20 AM, during an interview, the Director of Nursing (DON) stated that the four residents on the MDRO list did not require Contact Precautions because their wounds were not active, referred to CMS guidelines. The surveyor informed the DON that the IP had previously identified the list as Contact Precautions, which contradicted physician orders and diagnoses. Upon reviewing the physician orders, the DON acknowledged that Resident #4 did not actually have Shingles. The surveyor expressed concern that resident precaution statuses did not match physician orders or diagnoses, and that facility staff demonstrated a lack of clear understanding regarding the distinction between Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). The DON validated the findings. 2)On 7/20/26 at 7:40 AM, the surveyor conducted an environmental tour of the laundry room accompanied by Environmental Services (EVS) Director #3. A laundry cart in the washroom contained several plastic bags of used linens along with exposed, unbagged dirty linens. EVS Director #3 stated that the cart had been delivered by nursing floor staff, adding: This cart might have already been sorted by laundry staff since the washer was already full. All used linens should be placed in a plastic bag and tied. We sort them in the washroom right before putting them in the washer. On 7/20/26 at 7:49 AM, a laundry cart from the 1st floor was delivered to the washroom while the surveyor was present. The cart contained unbagged linens mixed with trash. EVS Director #3 confirmed that all used linens and trash should have been properly bagged prior to transport. On 7/20/26 at 7:56 AM, during an interview, Geriatric Nursing Assistant (GNA) #4 confirmed that all dirty linens must be bagged and tied before being placed in the soiled utility room. On 7/20/26 at 8:19 AM, during an interview, Infection Preventionist (IP) #5 verified that all dirty linens must be placed in a plastic bag and tied prior to transport from the soiled utility room to the main laundry room. The surveyor shared concerns regarding unbagged contaminated linens during transport, which IP #5 acknowledged. 3) On 7/22/2026 at 9:03 AM, during a medication administration observation, Certified Medication Aide (CMA) #17 was observed preparing the medications for Resident #76. While removing the Amlodipine tablet from its blister package, CMA #17 handled the tablet directly with his/her bare fingers before placing it into the medication cup for administration. On 7/22/2026 at 9:28 AM, while preparing medications for Resident #41, CMA#17 again removed a Hydralazine tablet from its blister package and handled the medication directly with his/her bare fingers before placing it into the medication cup. On 7/22/2026 at 9:35 AM, the surveyor informed CMA #17 of the infection control concern. CMA #17 stated, I use my hand to catch the medication and prevent it from falling. On 7/22/2026 at 9:40 AM, during an interview, Licensed Practical Nurse (LPN) #18 stated that staff were expected to avoid touching tablets or capsule with their bare hands during medication preparation. LPN #18 stated that the medication cup should be held directly beneath the blister pack, so the medication falls into the cup without hand contact thereby reducing the risk of contamination and maintaining appropriate infection control practices. On 7/23/2026 at 9:36 AM, the Director of Nursing (DON) was notified of the findings and acknowledged the concern.

Based on a review of medical records, facility records, and staff interviews, it was determined that the facility failed to effectively monitor and track antibiotic usage. Specifically, an antibiotic was prescribed to a resident without clinical evidence of infection, and the facility's Antibiotic Stewardship Program failed to document all prescribed antibiotics. This affected three (Resident #30, #39, and #57) out of 18 residents reviewed for antibiotic use and stewardship during the annual survey.The findings include:As part of the Infection Control survey task, the surveyor requested and reviewed the facility's antibiotic stewardship binder on 7/20/26 at 8:35 AM. A review of the binder revealed that the facility utilized a monthly analytical report titled Infection Surveillance Report for antibiotic stewardship. This report listed residents by infection category and included the resident's name, date of birth , infection onset date, specific infection, signs and symptoms, status, and pharmacy order details (medication name, order date, prescriber, and comments). However, the report failed to include the duration of antibiotic therapy and documentation of laboratory report reviews to determine medical necessity.During an interview on 7/20/26 at 10:00 AM, the Infection Preventionist (IP) stated that resident infection status and antibiotic use were discussed during weekly risk meetings. She displayed the cloud-based electronic medical record screen she uses to track antibiotic stewardship data. The surveyor requested a printout of the records for the most recent 14 days.On 7/20/26 at 10:55 AM, the surveyor reviewed the IP's printed records, which listed 18 residents receiving antibiotics. However, the documentation lacked essential tracking information and accuracy:-Resident #57 was ordered Cephalexin 500 mg capsules from 7/13/26 to 7/20/26 with the general indication listed as Infection. There was no physician progress note specifying the exact diagnosis or clinical evidence supporting the infection.-Resident #30 was listed as receiving Meropenem-Sodium 500 mg/50 mL for osteomyelitis from 7/11/26 to 7/29/26. However, a review of the medical record revealed the antibiotic had actually been initiated upon admission on [DATE].-Resident #39 was listed as receiving Acyclovir 200 mg for herpes zoster from 7/10/26 to 8/06/26. However, the medical record indicated the medication was initiated on 7/08/26.During an interview on 7/20/26 at 1:30 PM, the surveyor reviewed the printed antibiotic log with the Director of Nursing (DON) and the IP. The surveyor expressed concerns that the tracking data for Residents #57, #30, and #39 was incomplete and inaccurate, and therefore failed to meet regulatory requirements for antibiotic stewardship. Both the DON and IP confirmed these findings.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure staff members' COVID-19 vaccination statuses were monitored and documented. This affected two (Geriatric Nursing Assistants #11 and #12) of five staff members reviewed immunization records during the annual survey.The findings include:The COVID-19 vaccine provides acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19).On 7/21/26 at approximately 7:00 AM, a review of staff immunization records revealed that two of five reviewed employee health files lacked documentation of COVID-19 vaccination status:-GNA #11 was hired in December 2025 as direct care staff and lacked documentation of COVID-19 vaccination status in the employee health file.-GNA #12 was hired in September 2025 as direct care staff and lacked documentation of COVID-19 vaccination status in the employee health file.On 7/20/26 at 8:19 AM, during an interview with the Infection Preventionist (IP), she stated that Human Resources reviews new employee immunizations, while the IP reviews staff COVID-19 and influenza vaccination statuses. The surveyor subsequently reviewed the health files for GNA #11 and GNA #12 with the IP and the Director of Nursing (DON). They confirmed and validated that the employee health files lacked required documentation regarding COVID-19 vaccination status.

Based on a review of staff training records and staff interview it was determined that the facility staff failed to ensure all staff were annually trained in Quality Assurance and Performance Improvement (QAPI). This was evident for 2 (Staff #22 and #23) out of 6 staff training records reviewed. The findings include: During a review of employee training records on 7/23/26 it was revealed that Staff #22 and Staff #23 had not been trained in QAPI since each were hired by the nursing home. The Director of Nursing was interviewed on 7/23/26 at 8:30 AM. This surveyor asked if she was aware that the staff members have not been trained in QAPI. She said she would have to investigate and would produce evidence if she found it. No trainings for these staff were provided prior to the exit conference.

Based on a review of employee training files and staff interview it was determined that the facility staff to ensure all staff received 12 or more hours of training each year. This was evident for 3 (Staff #21, #22, and #23) out of 6 employee records reviewed. The findings include: During a review of employee training records on 7/23/26 it was revealed that Staff #21, Staff #22, and Staff #23 had not received 12 or more hours of annual training by the nursing home and/or via online courses provided by the nursing home.The Director of Nursing was interviewed on 7/23/26 at 8:30 AM. This surveyor asked if she was aware that the staff members have not received the mandatory 12 or more hours of training each year. She said she would have to investigate and would produce evidence if she found it. No evidence that these three staff had 12 or more hours of training in the past year were provided prior to the exit conference.

Based on observations, interviews, and record review, the facility failed to ensure residents were treated with dignity and respect when staff publicly labeled residents as feeders on a dry erase board visible from the hallway and nurse's station. This practice compromised resident dignity, confidentiality, and privacy rights and affected Resident (R) #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35 and was observed during the complaint survey.Findings include:On 4/27/26 at 10:47 AM, 4/28/26 at 11:29 AM, 4/28/26 at 10:02 PM, 4/29/26 at 12:47 AM, and 4/30/26 at 10:05 AM, the surveyor observed a dry erase board located on the second floor next to the nurse's station. The board listed the above room numbers for Residents #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35 under a heading identifying the residents as feeders. The board was visible to staff, visitors, and anyone passing through the area, allowing resident care needs to be publicly disclosed.During an interview on 4/28/26 at 10:11 PM, GNA #15 stated that residents who are total care receive assistance with feeding and acknowledged the term feeders is used, although the staff member did not have any on the assignment.During an interview on 4/29/26 at 12:32 PM, GNA #8 stated that feeders refers to residents needing assistance with eating and acknowledged that staff should not refer to residents as feeders on the board due to privacy concerns.During an interview on 4/29/26 at 2:13 PM, GNA #11 stated that residents who require feeding assistance are identified by room number on the dry erase board and confirmed the sign is visible for everyone to see.During an interview on 4/29/26 at 3:07 PM, GNA #10 stated the dry erase board identifies feeders and their room numbers.During an interview on 5/1/26 at 10:15 AM, Unit Manager (UM) #26 stated staff should not refer to residents as feeders because it labels them and may make them feel incapable. UM #26 stated all would be in-serviced regarding appropriate terminology, including changing the terminology to assist with meals and emphasized that staff are expected to use appropriate, respectful language when referring to resident care.Record review on 5/1/26 at 10:41 AM of the facility's policy titled Dignity dated 2/21 documented: Staff speak respectfully to residents at all times, including addressing the residents by his or her name of choice and not 'labeling' or referring to the resident by his or her room number, diagnosis, or care needs.

Based on interviews and record review, the facility failed to ensure that an allegation of verbal abuse was reported and handled in accordance with Centers for Medicare and Medicaid Services (CMS) requirements for 1 (Resident #12) of 1 resident reviewed for abuse allegations during the complaint survey. The Findings include:Record review on 4/27/26 at 10:09 am revealed Resident #12 was admitted on [DATE] with diagnoses including dementia with behavioral disturbance, hemiplegia, HIV disease, dysphagia, and cognitive communication deficits.An examination of the Facility Reported Incident (FRI) on 4/30/26 at 2:30 pm revealed an anonymous allegation was received stating that Resident #12's, daughter was verbally abusive toward the resident. Per the FRI, staff and the Administrator became aware of the allegation on 10/31/25 at 10:00 am, contacted the local police department at on 10/31/25 at 10:05 am, reported the allegation to the resident's representative who was also the alleged perpetrator on 10/31/25 at 10:30 am, and the local Ombudsman's office on 10/31/25 at 11:12 am. The facility documented that the allegation was not verified, but the investigation was compromised by notifying the alleged perpetrator. There was no documentation that the facility protected the resident from potential retaliation during the investigation.During an interview on 5/1/26 at 10:57am, the Assistant Director of Nursing (ADON #3) stated that if the alleged abuser is in the building, we remove them but we don't tell them that they have an allegation of abuse against them, which contradicts the Administrator's actions.During an interview on 5/1/26 at 11:04 am, the Director of Nursing (DON #2) stated that when the alleged perpetrator is a family member, the facility tells them There is a reason to not let them in the building and that we don't say who the allegation is about, but acknowledged the Administrator may have done so.During an interview on 5/1/26 at 11:44 am, the Administrator stated that the resident's representative (the daughter) was notified of the allegation. The Administrator confirmed awareness that the resident's representative was the alleged perpetrator, stating: We let them know that the allegation of abuse is against them. We inform the guest that they are not allowed in the building. We provide enough information to get a statement. We would contact him/her to let them know that there was an allegation of abuse. The Administrator further stated that the representative was restricted from the building from the point we were made aware until we finalized the investigation. When the surveyor informed the Administrator that CMS regulations prohibit informing the alleged perpetrator of an allegation during the investigative process, as doing so may compromise the investigation and place the resident at risk, the Administrator stated he was unaware. Facility leadership confirmed this was standard practice.

Based on interviews and record review, the facility failed to ensure the clinical record was accurate, complete, and consistent for 1 (Resident #17) of 1 resident reviewed for an unexpected change in condition during the complaint survey. The findings include:During a record review on [DATE] at 12:27 pm, it was revealed that Resident #17 was admitted on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, obstructive sleep apnea, chronic kidney disease, and malnutrition.An examination of a progress note dated [DATE] at 9:36 am written by LPN#6, for Resident #17 on [DATE] at 1:25 pm indicated the resident expired on [DATE] following an early morning change in condition. The change of condition was documented in the vital sign log dated [DATE] for oxygen saturations at 4:45 am, showing oxygen saturation at 60% and in the progress note the Licensed Practical Nurse (LPN #6) documented checking on the resident at 4:45 am and stated .Shortly afterward, during morning medication administration, the writer (LPN #6) approached the patient and found him/her unresponsive. A rapid assessment was performed, and at 5:52 am, CPR was initiated with the use of an AED. Emergency medical services were contacted at 5:53 am. EMS arrived at approximately 6:00 am and assumed resuscitation efforts. Despite continued attempts to revive him/her, the patient was pronounced deceased at 6:25 am.A record review on [DATE] at 12:01 am of Resident #17's physician's orders dated [DATE] reflected an order for Bi-level Positive Airway Pressure (Bi-PAP), which provided two different pressure levels, a higher-pressure during inhalation and a lower pressure during exhalation. The order specified use at bedtime and as needed for naps, with instructions to check placement and functioning when applied. LPN #6 documented that the resident had a Continuous Positive Airway Pressure (CPAP), which delivers one single, continuous level of pressure during both inhalation and exhalation.During an interview on [DATE] at 11:47 pm, LPN #6 stated Resident #17's oxygen saturation was 60% at approximately 4:45 am. The nurse stated the resident was not wearing his/her BiPAP at 11 pm, that there was no documentation of the refusal to wear the device, that the CPAP was applied around 1:00 am, and that after the phlebotomist drew blood, the nurse checked the oxygen saturation and blood sugar, offered fluids, and left the room. The nurse stated the resident was later found unresponsive.During a second interview on [DATE] at 6:40 am, LPN #6 again referenced the 60% oxygen saturation and stated Resident #17 had been active earlier in the shift with a nasal cannula and referenced a CPAP in place.During a third interview on [DATE] at 1:07 pm, conducted in the conference room with the survey team present, LPN #6 changed the account and stated Resident #17's oxygen saturation had been 90%, not 60%. The nurse stated they did not add a third liter of oxygen, contradicting prior interviews. The nurse also stated the oxygen concentrator was beeping and that they changed the resident from the concentrator to an oxygen tank. This information had not been previously reported and was not documented in the EMR. When asked why the concentrator alarmed, the nurse stated they were not a mechanic.During an interview on [DATE] at 3:11 pm, the Nurse Supervisor (RNS #21) stated LPN #6 approached her at approximately 5:55 am and reported the resident was unresponsive and that the nurse didn't know what was wrong. The supervisor stated the resident had no pulse and no respirations and was wearing a nasal cannula connected to an oxygen tank. The supervisor stated LPN #6 did not report any prior low oxygen saturation, alarms, or equipment issues. The supervisor also stated they were unable to reach the on-call provider and contacted the medical director, which was also not documented.During an interview on [DATE] at 11:35 am, the provider (MD #22) stated they were not notified of any change in condition prior to being informed that the resident had expired.During an interview on [DATE] at 11:25 am, the contracted laboratory's Chief Operating Officer stated the phlebotomist drew blood at 4:39 am and that a facility staff member accompanies the phlebotomist to verify identity. There was no documentation in the EMR of the nurse's presence, assessment, or any post phlebotomy monitoring.During an interview on [DATE] at 11:04 AM, the Director of Nursing stated documentation is expected to reflect what staff observed and did. The DON stated that if the EMR entry dated/time' was corrected it would look like a falsification and that a 60% oxygen saturation would represent a significant change in condition requiring immediate intervention, which was not documented.

Based on observations, interviews, clinical record review, and review of facility policy, the facility failed to maintain an infection control program that would prevent and protect residents from the risk of infection for two (2) (Resident #14 and Resident #15) of 35 sampled residents reviewed during the complaint survey.The findings include: Review on 5/1/26 at 11:15 AM of the facility's Enhanced Barrier Precautions policy dated 2001 (Med-Pass) noted 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when.b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained.7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). B. Personal protective equipment (PPE) is changed before caring for another resident.8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care).16. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required. Review on 4/28/26 at 3:00 PM of R#14's clinical record revealed the resident was admitted into the facility on 4/16/26 with diagnoses of a fracture of unspecified part of neck of right femur, muscle wasting and atrophy, chronic kidney disease and acute pulmonary edema. Observation on 4/27/26 at 12:04 PM revealed Geriatric Nursing Aide (GNA) #7 threw away a bag of trash outside of R#15's room door. There was an Enhanced Barrier Precaution sign posted on the door. GNA #7 was not wearing personal protective equipment (PPE) when they threw the material away in the trash can. Without hand hygiene and without putting on PPE, GNA #7 returned to the resident's bedside to continue providing care behind the privacy curtain in the room. At 12:22 PM, GNA #7 completed the task of assisting R#15 in getting dressed and transferring from their bed to their wheelchair. GNA #7 did not put on required PPE while assisting R#15 in getting dressed and transferring. Observation in R#14's room on 4/27/26 at 12:25 PM revealed Occupational Therapist (OT) #12 worked with R#14 in completing exercises of the bilateral upper extremities. OT #12 instructed the resident to lift weights for a set of 10. OT #12 placed their hands on R#14's bare arm and assisted the resident in completing sets of 10. OT #12 and R#14 had skin-to-skin contact. Observation on 4/28/26 at 9:56 PM revealed GNA #14 was providing care to R#14 behind a privacy curtain in the resident's room. There was an Enhanced Barrier Precaution sign posted on the door. The aide's feet were seen walking from one side of the resident's bed to the other. At 10:00 PM, GNA #14 walked from behind R#14's privacy curtain and removed their gloves and threw the gloves away in the trash. GNA #14 was not wearing a PPE as required for EBP. In an interview on 4/27/26 at 12:30 PM, GNA #7 was asked what type of PPE was required for EBP as posted on Resident #15's door. The aide said that PPE was required when providing direct care to residents. GNA #7 said that they were wearing a gown, gloves, and a mask earlier when they assisted the R#15 with a bed bath; however, the aide confirmed they did not put on the required PPE when they assisted the resident in getting dressed and transferring them to their wheelchair. During an Interview on 4/27/26 at 12:36 PM, OT #12 confirmed the therapist was working with Resident #14. During the interview, the therapist said that PPE was not required when working with R#14 because the resident had a catheter and the therapist did not have to come in contact with any bodily fluids. The therapist acknowledged he/she touched R#14 to assist them in lifting the weights during the exercises. OT #12 said that they sanitized their hands before and after working with the resident but did not wear PPE.In an interview on 4/28/26 at 10:02 PM, GNA #14 confirmed that they were changing R#14's brief after the resident had a bowel movement and confirmed that he/she were not wearing a gown during the incontinent care procedure. When asked what type of PPE was required for incontinent care for residents on EBP, GNA #14 said a gown and gloves were required. GNA #14 said that he/she usually wore a gown. In an interview on 4/29/26 at 12:31 PM, GNA #8 said that for EBP, staff were to put on gloves and gowns when providing direct contact care to residents. GNA #8 said that 'washing and dressing' a resident were examples of high contact care. Interview on 4/29/26 at 1:28 PM with GNA #9 revealed that staff were to wear gown, gloves and mask for EBP to protect the resident from potential infection. GNA #9 said that EBP were to be used for skin-to-skin contact when providing resident care. In an interview on 4/29/26 at 3:06 PM, GNA #10 said that EBP included hand hygiene when going into and out of a resident's room; and required wearing gloves and a gown each time staff provided care. Review on 5/1/26 at 10:50 AM of R#14's Physician's Order dated 4/27/26 revealed R#14 had orders for EBP due to the resident's indwelling catheter and wound. During an interview on 5/1/26 at 11:04 AM, the facility's Director of Nursing (DON) said that staff should wear gloves and gown when providing high contact care to residents with Enhanced Barrier Precautions. The DON said that included when therapy staff provided skin-to-skin contact and support during therapy services.

Based on record review, interviews and observations, it was determined that the facility staff failed to adequately monitor a cognitively impaired resident who had exit seeking behaviors. This was found to be evident for 1 (#217) out of 2 residents reviewed for exit seeking behaviors during the recertification survey. This deficient practice was determined to be an Immediate Jeopardy past non-compliance after the investigation was completed. The findings include: A review of Resident #217 electronic medical record (EMR) on 06/11/25 revealed on 11/11/24 Resident #217 left their room located on the first floor and went to the front desk and attempted to leave the facility. After the attempted elopement, the resident was recommended to have a monitoring device placed to notify the facility staff if the resident attempted to leave the building. The elopement assessment dated [DATE] indicated the resident had a Wanderguard bracelet placed. On 06/11/25 at 11:48 AM a review of the facility's investigation related to the facility reported incident (FRI) #MD00216062 revealed on 03/24/25 at 12:30 AM the nursing staff on the second floor noted Resident #217 was missing. It was reported the resident was last seen by staff at 12:20 AM at the nurse's station. The Wanderguard system was alarming on the second floor, and the staff was unable to locate the resident within the facility or outside on the grounds; the police were notified. At 3:11 AM local authorities notified the facility staff the resident was found around Exit 17 towards Interstate 695. The resident was returned to the facility at 3:28 AM. The incident was reported to the state agency on 03/25/25 at 12:19 AM which was outside the two-hour allotted timeframe to report the incident. On 06/12/25 at 8:31AM during an interview with the Administrator the surveyor asked, how did Resident #217 get out of the building. The Administrator verbalized apparently he/she went out the front entrance. The wander guard pads did not go off; we determined that it was related to a power surge. The front door was ajar, and the system did not alarm. None of the staff heard the alarms. Our company determined that it was related to a power surge. During an interview with Maintenance Director #8 the surveyor asked what caused the front door to malfunction. Maintenance Director #8 verbalized a visitor could have pulled the door before the switch opened the door creating a short of the mag lock causing the door to malfunction. The surveyor asked if there was a visitor in the building at midnight. The Administrator verbalized visiting hours are not restricted. The surveyor asked if there was another power surge how they would ensure the residents' safety. Maintenance Director #8 verbalized if the door doesn't lock it would alarm. The staff would know the door was locked because it would not open. If the door won't open they can open it. The surveyor reviewed documentation that verified the front door was repaired on 03/26/25 and a Wanderguard system was applied to the elevator on 03/27/25. Further review of the EMR revealed Resident #217 was wheelchair bound and had a facility acquired Stage III wound to his left heel and a right below the knee amputation (BKA). According to documentation in the resident's electronic medical record (EMR), the resident propelled their wheelchair with his/her left foot. On 03/20/25 the left heel wound measured 3.8 cm in length (L) x 1.6 cm width (W) x 0.3 cm depth (D). After the elopement there were no documented wound measurements in the EMR. The next documented wound measurements were taken over three days later 03/27/25; the measurements were 4.2 cm (L) x 2.0 cm (W) x 0.3 cm (D) which was a decline in the wound. On 06/18/2025 at 6:57 AM, the Administrator acknowledged the incident was a high-level concern. On 06/18/2025 at 12:55 PM, the surveyor verified all the facility staff were educated regarding elopement prevention on 03/29/25. The Administrator was made aware 03/29/25 was the Immediate Jeopardy (IJ) past non-compliance date. Three staff who worked on 03/29/25 during the 11:00 PM - 7:00 AM shift were educated about elopement policies including Wanderguard Management.

Based on documentation review and interview, it was determined that the facility staff failed to protect a dependent resident from an accident with injury. This was evident for 2 of 3 (#33, #27) residents reviewed for accidents and caused harm to Resident #33 and Resident #27. The findings include: 1) On 8/26/22 at 7:45 AM review of Resident #33's medical record revealed Resident #33 was admitted to the facility in April 2022 with diagnoses that included but were not limited to cerebral infarction, [CONDITION(S)], abnormal bleeding and morbid (severe) obesity. A 7/30/22 physician's progress note documented, mobility and ADL (activities of daily living) impairment, weakness and debility secondary to multiple complex comorbidities. The progress note documented active medical problems included [CONDITION(S)] and cerebral infarction. [CONDITION(S)] is a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension. [CONDITION(S)] leaves a person unable to communicate effectively with others. A cerebral infarction (also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area. It was also noted during record review that Resident #33 was prescribed [MEDICATION(S)] 5 milligrams twice per day. [MEDICATION(S)] is a blood thinner that reduces blood clotting and can cause bleeding. On 8/26/22 at 7:45 AM review of facility reported incident (FRI) MD 727 documented that on 8/4/22 at approximately 3:00 PM, Geriatric Nursing Assistant (GNA) #9 was providing care to Resident #33 and while providing care, Resident #33 rolled off the bed and sustained a hematoma to the left side of his/her head. Resident #33 was sent out to the hospital. A hematoma is a mass of usually clotted blood that forms in a tissue, organ, or body space as a result of a broken blood vessel. Review of a written statement by LPN #10 documented, I found the resident flat on the floor on [his/her] left hand, and [he/she] reported that [he/she] hit [his/her] head on the floor. The statement continued, the GNA said she was providing perineal care alone and the resident flipped over and fell on the floor. The GNA reported she was providing (care) alone and tried to turn the resident when [he/she] flipped over and fell from the bed to the floor. Review of a written statement by RN #11 documented, assigned caregiver informed this nurse that patient fell off from the bed during perineal care. Pt. fell on [his/her] left side. GNA was providing care to the patient by herself. Patient was lying on left side and screaming for help to get back in bed. Review of a written statement by GNA #9 documented, I was in the middle of cleaning up the patient in room [number], and I had [his/her] leg over the other. I was holding on to [him/her], because I was almost finished, and that is when [he/she] fell off the side of the bed. Review of a written statement by LPN #12 documented, patient was receiving a diaper change by aide when patient fell . Aid taking care of patient stated she was changing patient alone before [he/she] fell . Review of a Pain Assessment for Resident #33 dated 8/4/22 documented, moderate pain - headache: What appears to increase the resident's pain: Hematoma: What appears to relieve the resident's pain: sent out 911. Comments: patient fall sustained hematoma and sent out 911. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #33's MDS with an assessment reference date (ARD) of 6/25/22 documented the resident was coded as extensive assist with at least 2 people for bed mobility and transfer. Resident #33 was coded extensive assistance with at least 1 person for dressing, toilet use and hygiene. Review of Resident #33's care plan, I have an ADL Self Care Performance Deficit r/t impaired balance that was initiated on 5/7/22, had the interventions, praise all efforts at self care, PT/OT evaluation and treatment as per MD orders, encourage me to discuss feelings about self-care deficit. The care plan was not resident centered as the care plan failed to state how many staff were needed to provide bed mobility and patient care as the resident was coded extensive assist per the MDS assessment. On 8/26/22 at 11:30 AM an interview was conducted with GNA #12, who was currently assigned to Resident #33. GNA #12 was asked how she took care of Resident #33 and stated, I make sure everything is prepared before I start. I make sure someone is with me because [he/she] is so big and to help guide [him/her]. When asked if GNA #12 felt she could take care of Resident #33 by herself she stated, No, I don't feel I can by myself. I need help with [him/her]. [He/She] is a 2 person assist. If the patient can help then I will do by myself but when they are big, I call for someone to help me. GNA #12 stated, [He/She] can help but most of the time [he/she] will say I am scared so I just call someone to help me. When asked if Resident #33 felt scared before the fall GNA #12 said, not that I know of. GNA #12 stated, we don't have side rails on the beds. [He/She] cannot turn side to side by [him/herself]. GNA #12 said she has to put Resident #33's leg over the other leg and then put her arm over Resident #33's shoulder and give a little push. She stated that she has another person help so the resident is safe. Review of GNA #9's personnel file on 8/26/22 revealed a pre-term checklist dated 8/10/22 which documented a brief description of the event surrounding the decision for possible termination. On 8/3/22 GNA #9 used a Hoyer lift by herself, and a resident got hurt, sustaining a skin tear. It was documented that Human Resources and the Director of Nursing (DON) spoke to GNA #9 about using the lift with 2 GNAs. GNA #9 was suspended pending investigation, due to not following resident's plan of care for 2 persons assist w/bed mobility and mechanical lift of 2 person. Resident sustained skin tear to the left upper extremity. Assigned GNA was utilizing the mechanical lift alone which caused injury to left upper extremity. It was then documented on 8/4/22 that GNA #9, worked with a bariatric resident cleaning [him/her], turn [him/her] by herself and resident fell - went to hospital. GNA #9 was terminated on 8/12/22. On 8/29/22 at 9:53 AM an interview was conducted with GNA #9. GNA #9 told the surveyor that she was changing Resident #33 and had pulled the resident towards her, and Resident #33 was turned facing the door. GNA #9 stated she was almost finished when Resident #33 rolled out of bed. GNA #9 stated, [He/She] was a 2 person assist and I should have gotten help. I learned a lot from that, and I will never do that again. Usually, other people get someone to help them, and I did not, I changed [him/her] by myself and that was poor judgement on my part. I should have had someone else help me. 2) On 8/29/22 at 8:00 AM a review of Resident #27's medical record revealed a 8/13/22 physician's progress note that documented Resident #27 was admitted to the facility in July 2022 with diagnoses that included but were not limited to: Cerebral infarction, [CONDITION(S)] and [CONDITION(S)] affecting right dominant side, [CONDITION(S)], seizures, [CONDITION(S)], hypertension, unspecified lack of coordination, [CONDITION(S)] following cerebral infarction, ambulatory dysfunction, unsteadiness on feet and other symptoms and signs involving the musculoskeletal system. [CONDITION(S)] is a neurological disorder characterized by the inability to perform learned (familiar) movements on command, even though the command is understood and there is a willingness to perform the movement. Both the desire and the capacity to move are present but the person simply cannot execute the act. On 8/29/22 at 8:00 AM a review of Facility Reported Incident MD 638 documented that on 8/19/22 at approximately 6:20 PM, GNA #14 was transferring Resident #27 from the wheelchair to the shower chair when Resident #27 lost his/her balance and had to be lowered to the floor. At that time the only visible injury was a fluid filled blister to the right toe and abrasion to the right bunion. With help from 2 other staff, Resident #27 was put back into the shower chair via Hoyer lift. Resident #27 denied having any pain. On 8/29/22 a review of GNA #14's written statement documented that she was transferring the resident from the wheelchair to the shower chair, the resident lost his/her balance and GNA #14 helped the resident to the floor so the resident would not hit his/her head on the floor. A written statement from Resident #27 documented, On 8/19/22 I asked the GNA for a shower. It was not my shower time, but she was kind enough to give it to me. I left the room in my w/c to the shower room. The GNA had the shower chair in the shower room. I held on to the grab bar in the shower room while trying to be transferred to the shower chair from the w/c when my leg gave way. The GNA assisted me by lowering me down to the floor. Continued review of Resident #27's medical record revealed 2 physician certifications dated 8/3/22 that Resident #27 lacked decision making capacity due to the cerebral infarction. 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. A series of standardized questions in the BIMS are scored and when added result in a total score between 0-15. The numeric value falls into one of three cognitive categories: Intact which is 13 to 15 points, Moderate which is 8 to 12 points or Severe cognitive impairment which is 0 to 7 points. Review of Resident #27's admission MDS with an assessment reference date (ARD) of 8/4/22, Section C, Cognition documented the BIMS (Brief Interview of Mental Status) was 10. Section G, Functional Status, documented that Resident #27 was extensive assistance with 2 or more people for bed mobility, transfers, and toilet use. Review of Resident #27's care plan, I have an ADL (activities of daily living) Self Care Performance Deficit r/t impaired balance that was initiated on 7/29/22 documented the interventions, I require 2 person assist with transfers with mechanical lift which was initiated on 7/29/22. The care plan also documented, I require 1 person assist with transfers which was initiated on 7/29/22. This was the care plan in the electronic medical system (EMR). The paper copy of the care plan that the Director of Nursing (DON) gave the surveyor on 8/29/22 documented, I require 1 person assist with transfers, and I require 2 person assist for bed mobility. The initiation date was 7/29/22. On 8/29/22 at 9:25 AM an interview was conducted with the DON who stated, after the fall, when they went in the system to update the care plan, they added 2 person for transfer and the date didn't change. Continued interview of the DON on 8/29/22 at 9:25 AM revealed during the investigation that GNA #14 turned on the water in the shower and then placed Resident #27 in front of the grab bar in the shower. The DON stated, because the floor was wet from the running water in the shower, she (GNA #14) placed a towel on the floor in front of the resident and stood slightly behind the resident as [he/she] used the grab bar. The resident was at the end of the grab bar instead of in the middle. The resident's hands were not positioned far apart, they were close together. The resident had muscle weakness and the resident told me that [his/her] leg gave out. The resident was lowered to the floor. The DON was asked if GNA #14 received education and she stated, she received verbal education because of the way she transferred the resident. [He/She] was not in the center of the bar and [his/her] hands were not spread out and the water was running. The verbal education report was requested from the DON; however, she said it was verbal and she did not have a copy. However, on 8/30/22 at 9:35 AM the NHA gave the surveyor GNA #14's employee file and there was a verbal notice for improper transfer technique that was given to the employee on 8/29/22. On 8/29/22 at 12:33 PM observation was made of the first-floor North hallway shower room. It was on the same side of the hall that Resident #27's room was on. As you walked in the room there was an alcove to the left where the toilet was located. The second alcove on the left was the first shower stall. It was 95 inches (7.9 ft.) from the opening of the stall to the back wall and it was 50 inches (4.16 feet) wide. There was a grab bar attached to the left wall that was 5 ft. from the opening of the alcove. The grab bar was attached under the handheld shower head/wand. The grab bar was 32 inches to the back wall and was 21 inches around the back wall. There was a tile floor. On 8/30/22 at 9:50 AM GNA #14 was interviewed and stated, the water was running, and the water was hitting the wall and not the resident. The water wand was on the grab bar facing the wall. The floor was already wet because someone had used it prior. I put a towel on the floor for the resident to stand on. I don't know what happened. [He/She] had stood up for me prior to the incident. [He/She] had been standing for me to put [him/her] on the Geri chair (shower chair) before. GNA #14 stated, I put the shower head on the rail before turning the water on. When asked if she received education after the incident, GNA #14 stated, I was suspended because I should not have transferred someone alone without knowing their history. After I came back, I was educated on using the Hoyer lift, to stop transferring the resident alone, and to get help with transferring. On 8/30/22 at 10:30 AM an interview was conducted with LPN #15 who stated, the resident's pain level was about a 6 and [he/she] complained of lower leg pain, painful to touch. On 8/30/22 continued review of Resident #27's medical record revealed the physician was notified of the fall on 8/19/22 at 6:30 PM and ordered an x-ray of the right lower leg/right great toe. On 8/19/22 at 21:53 (9:53 PM) the nurse documented that the resident had no pain and was still waiting for the x-ray technician. On 8/20/22 at 4:44 AM the nurse notified the physician that the resident was experiencing pain. The nurse administered Tylenol 1,000 mg. that was effective. On 8/20/22 at 17:35 (5:35 PM) the physician was notified of the x-ray result and the physician ordered for Resident #27 to be sent out to the hospital. Further review of the medical record revealed an x-ray report dated 8/20/22. The report documented the examination date was 8/20/22 at 9:21 AM and the report date of the results was 8/20/22 at 11:45 AM. There was no documentation in the medical record of physician notification from 11:45 AM until 5:35 PM. The x-ray results report documented, there is a fracture of the distal tibia and fibula with swelling. There is osteopenia and [CONDITION(S)]. Impression: acute fracture of the distal fibula and tibia in near anatomic alignment. The tibia and fibula are the two long bones located in the lower leg. The tibia is a larger bone on the inside, and the fibula is a smaller bone on the outside. The tibia is much thicker than the fibula. It is the main weight-bearing bone of the two. On 8/29/22 at 1:00 PM Licensed Practical Nurse (LPN) #7 was interviewed and stated she has worked at the facility less than 2 weeks. LPN #7 stated, it was a Saturday, and I was on my own for the first time. That day they did an x-ray. I was expecting them to fax over the results. I was checking the fax machine and I didn't see anything and that was my first day on the floor. LPN #7 stated that she forgot to mention that she was still waiting for the x-ray results to the oncoming nurse. LPN #7 stated that the nurse that came after her found the result of the x-ray in the reporting system. LPN #7 stated, I totally forgot about it. LPN #7 stated, no one educated me after that. LPN #7 stated, I had 19 patients that I had to do a COVID assessment on plus I was doing vitals and passing my meds. LPN #7 stated, it was hectic. I went PRN (when needed) because I can't do an effective job. As a skilled floor it is overwhelming.

Based on observations; the review of medical records, administrative reports, and other pertinent documentation; and interviews with facility staff, it was determined the facility failed to prevent Resident #33 from exiting the building unattended on 6/7/22; failed to develop and implement timely interventions to address Resident #93's exit-seeking behavior, and failed to ensure the facility's exterior doors were secured, alarmed, and functioning properly. The deficient practice was evident for 2 of 4 residents reviewed for elopement during the survey; however, the facility's failures had the potential to impact 4 of 4 residents identified as at risk for wandering or elopement. Additionally, the facility failed to ensure that all medication carts remained locked and secured this was evident one medication cart. On Tuesday, 6/8/22 at 12:00 a.m., an Immediate Jeopardy was called related to the facility's failure to implement measures for residents with exit-seeking behaviors and inability to secure and alarm the exterior doors to the building. On Wednesday, 6/8/22, the facility presented two corrective action plans (one at 2:54 a.m. and 3:15 a.m.) to address the immediate concern related to the elopement. These plans were not accepted by the Office of Health Care Quality surveyors. The third corrective action plan was presented to the survey team on 6/8/22 at 3:36 a.m. This plan was accepted by the surveyors and the Office of Health Care Quality at 3:46 a.m. that morning. On Wednesday, 6/23/22 at 1:30 p.m. the surveyors verified that the facility implemented the elements of their corrective action plan. The immediacy was removed at that time. After removal of the immediate jeopardy, the deficient practice remained at a scope and severity of a D. The findings include: On 6/7/22 at 6:58 a.m. While entering the building through the front door, Surveyor # observed facility staff running out the door. The staff stated they were looking for a resident. During an interview with Licensed Practical Nurse (LPN) #13 on 6/7/22 at 11:00 a.m., she stated she was passing medications to Resident #33 between 6:15 a.m. and 6:20 a.m. on 6/7/22. She said at that time the resident was standing at his/her door fully dressed. The resident had a handbag on his/her shoulder. LPN #13 stated around 7:05 a.m. on 6/7/22, Geriatric Nursing Assistant (GNA) #15, was looking out of the second-floor window and saw Resident #33 in the parking lot next to the dumpster. LPN #13 stated she redirected Resident #33 from the parking lot back to the building. During an interview with LPN Staff #8 on 6/7/22 at 1:30 p.m., she stated Resident #33's behaviors were escalating over the last few days. She also stated that Resident #33 was observed by the elevator stating s/he was going home. A review of Resident #33's facility medical records on 6/7/22 at 1:00 p.m., revealed the resident was admitted from another facility (hereby referred to as the Transferring Facility) on April 1, 2022. According to Resident #33's medical records, prior to admission, the transferring facility sent an Order Summary Report (fax date 03/10/22) to this facility regarding Resident #33. The order summary (dated as active on 2/22/22) instructed staff to check the placement of the resident's alert bracelet. Further review of the faxed documents revealed this facility also received a report regarding Resident #33's history of wandering. The report stated that Resident #33 was, found wandering around [his/her] apartment complex appearing confused and staring off. Neighbors called 911 and [s/he] was sent to the hospital. Further review of Resident #33's record revealed the resident ' s admitting diagnosis included: [CONDITION(S)], Dementia with behavioral disturbance and cognitive-communication deficit. On 6/07/22 continued review of Resident #33's record revealed that on 4/7/22 the facility assessed the resident as having a Brief Interview of Mental Status (BIMS) of 11/15, indicating moderate cognitive impairment. On 05/27/22 the facility updated Resident #33 ' s care plan to indicate the resident displayed aggressive behavior disturbances. There was no evidence that Resident #33 ' s care plan addressed the resident's history of wandering nor did the care plan indicate the resident was at risk for elopement prior to the resident exiting the building the morning of 6/7/22. On 6/7/22 at 6:00 p.m. surveyors, # and # , reviewed the facility's monitoring/surveillance footage to determine how Resident #33 exited the building. Observation of the footage revealed on 6/7/22 at 6:58 a.m. Receptionist #18 handed Resident #33 a face mask prior to the resident walking out of the front door. A review of Resident #33's medical record on 6/7/22 at 2:00 p.m. failed to reveal documentation regarding Resident #33's behaviors related to expressing the desire to leave the facility. Further review of Resident #33's record revealed on 6/7/22 a care plan was initiated to address the resident's elopement after the resident left the building unsupervised that day. There was no care plan in place to address the resident's history of wandering, as reported by the Transferring Facility. 2. On 6/7/22 at 2:15 p.m. an interview with Registered Nurse (RN) #17 revealed that Resident #93 attempted to elope from the facility on 6/6/22. RN #17 stated the resident made it to the front door but was able to be redirected back to the unit. On 6/7/22 at 2:45 p.m. surveyor # reviewed Resident #93's record. According to the review, the resident was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, cerebral infarction, [CONDITION(S)], and anxiety. On 5/20/22 the facility documented the resident had a resident a BIMS of 9/15, indicating moderate cognitive impairment. On 5/27/2022 the facility's staff documented two separate events of Resident #93 displaying exit-seeking behaviors. Further review of the medical record on 6/7/22 at 3:30 p.m. failed to reveal any documentation regarding the resident ' s exit-seeking behaviors or attempt to elope, as displayed on 6/6/22, that were documented prior to 6/7/22. The record revealed that on 6/7/22, the facility initiated a care plan to address Resident #93's risk for elopement. 3. On 6/7/22 at 4:00 p.m. surveyors were accompanied by the Administrator (Staff #1), Director of Nursing (Staff #3), Maintenance Director (Staff #4), Electrician (Staff #7), Regional Director of Operations (Staff #2), and the Regional Director of Property Management (Staff #16) to check the facility ' s doors for proper function and operation. During this observation the following concerns were identified: Stairwell #1, on the first floor- the door failed to properly disengage the maglock after 15-30 seconds. A maglock is an electrified locking device that uses low-voltage power to keep an entrance secure, When the power is removed and/or the door is pushed for 15 seconds the maglock should release. Stairwell #2, on the first floor- the door failed to alarm and release after 15-30 seconds. Stairwell #4, on the first floor the door opened at 32 seconds but failed to alarm. Stairwell #4, on the second floor-the door, took 35 seconds to disengage; however, failed to alarm. First-floor dining room, the door did not alarm or disengage after 15-30 seconds. First-floor lounge the door did not disengage or alarm after 15-30 seconds Continued observation rounds on 6/7/22 revealed the facility has 11 keypads with a wander prevention system. Each keypad was checked for function. Observation revealed that 10 of 11 keypads failed to alarm when engaged by a wander guard device (braclet). A wander guard is bracelet that triggers alarms on lock monitored doors to prevent to help protect cognitively impaired residents against elopement. On 6/7/22 at 7:00 p.m. in an interview, Staff #2 acknowledge the surveyor's observations, then stated residents at risk for elopement (#28, #30, #33, #93,) will be placed under one-one supervision due to the facility's inability to alarm the wander guard system. On 6/9/22 at 10:00 a.m. the Life Safety Code Surveyor presented to the facility to check the alarm doors. The surveyor confirmed the facility ' s front doors were still not functioning properly. The Facility's Immediate Jeopardy Abatement Plan included the following actions: Facility respectfully submits the below allegation of compliance for F689 Accidents/Supervision. Residents at risk for elopement (#28, #30, #33, #93,) will be placed on one-one supervision on due to facility inability to alarm the wander guard system. Identify those residents who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: Resident #33 [is a redacted age and gender] admitted to the center on April 1, 2022]. Resident has multiple diagnoses that included dementia and cancer. Resident #93 [redacted age and gender] was admitted to the center on March 7, 2022. Resident has multiple diagnoses that include [CONDITION(S)] and cognitive impairment. Resident #33 exited the front door unattended on June 7, 2022. Once staff identified that the resident was outside of the building, the staff responded. Staff escorted the resident back into the center to her room. Nursing staff completed a full assessment and noted no injuries. Resident's attending physician assessed the resident and noted no injuries as well. Resident #33 was placed on 1:1 supervision. Nursing staff completed a Wander Elopement Risk Evaluation, which identified him/her at risk for elopement-note, prior evaluation assessed resident as not at risk. Nursing staff updated resident ' s care plan and placed a Wander Guard device on the resident. The physician and responsible party were notified. Nursing staff conducted a 100% head count. All residents were accounted for. Based on Wander Elopement Risk Evaluation completed on June 7, 2022, nursing staff received an order for a Wander guard device. Resident #93 was also placed on 1:1 supervision. Nursing staff updated Resident #93's care plan with new interventions. The physician and responsible party were notified. The center leadership was notified of the incident and initiated an investigation, which resulted in the center filing a Facility Reported Incident to the state on June 7, 2022. Center leadership conducted an Ad Hoc QAPI plan on June 7, 2022, and developed a quality assurance process improvement action plan. All residents have the potential to be affected. By June 8, 2022, the Director of Nursing and the clinical team completed an audit of all current residents to determine those at risk for elopement. For residents identified at risk for elopement, nursing updated their individual care plans to meet the residents' individual needs. Center leadership placed all residents, who triggered as an elopement risk, on 1:1 supervision. On June 7, 2022, Maintenance Director and regional Director of Property Management inspected all doors leading either to the exterior of the center or to a stairwell to confirm the functionality of door locks and the Wander guard system. All doors leading to the stairwells and the exit doors lock. Facility has hired a contractor to review the scope of work to allow for an audible alarm system to be installed at these doorways. That system would annunciate an alarm when a resident approach who is wearing a Wander guard Device. The work on system is expected to start on June 10, 2022, and should be completed by June 15, 2022. Maintenance Director or designee will check doors daily to confirm full functionality,specifically, as it relates to the doors locking. On June 8, 2022, Regional Property Manager will in-service maintenance director and assistant on the process by which doors are inspected for functionality. Maintenance Director will bring findings from audits to the Quality Assurance and process Improvement Committee meetings monthly for review until sustained compliance is achieved. Specify action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when action will be complete: On June 7, 2022, Nursing Home Administrator provided one-on-one education with the receptionist the was working at the time of the incident. This education included but was not limited to ensuring that all employees, visitors, and vendors check-in/out at the kiosk at the time of entrance and exit of the building, signing in and out on the visitor ' s log, the use of the visitors pass, and the Elopement binder. Nursing Home Administrator will educate all receptionist byJune 8, 2022. Also, on June 7, 2022, regional clinical support started education of all current staff (receptionist, licensed nurses, nurses' aides & certified medicine aides, therapy, dietary, housekeeping, maintenance, and department heads) on residents at risk for elopement, prevention of elopement and care and management of a resident that has eloped. Education included full-time, part-time and PRN and agency staff. Education will continue as new staff come onto their shifts. Education will be completed by June 17, 2022. No staff will be allowed to work until this education is completed. This education will be included as part of new hire orientation. On June 7, 2022, Director of Nursing educated nursing staff on Change of Condition Policy and Procedure, specifically as it relates to documenting change in behaviors. Education will continue as new staff come onto their shifts. Education will be completed June 17, 2022. No staff will be allowed to work until this education is completed. This education will be included as part of new hire orientation. Interdisciplinary team will review changes of condition Monday through Friday for three (3) months during clinical meeting to confirm that any changes are properly addressed. The Director of Nursing is responsible for the oversight of this process. The Director of Nursing and clinical leadership will review Wander Elopement Risk Evaluation for all new admissions, readmits, and residents who may experience a change of condition as part of the morning clinical meeting, Monday through Friday, for three (3) months. The Director of Nursing is responsible for the oversight of this process. The Director of Nursing will bring findings from audits to the Quality Assurance and process Improvement Committee meetings monthly for review until sustained compliance is achieved. Administrator is responsible for the implementation and oversight of this plan. Resident #28, #30, #33 and #93 who triggered for elopement risk is on 1:1 until the scope of work is completed. 4. On 6/8/22 at 11:30 AM an unlocked medication and unattended (by staff) medication cart was observed with the lock protruding out. The surveyor pulled the top drawer of the medication cart and it opened. Medications were observed in the medication cart. At that time the nurse, Staff #17, walked towards the cart and stated that she left the cart to grab something and then returned. The surveyor asked Staff #17 to explain the facility policy on securing the medication cart and she responded that the cart is to be always locked. The nurse went on to explain that the cart is to be locked so that residents who wander in the hall will not be able to get to the medications that are in the cart. The Administrator and DON were made aware of the concerns on 6/8/22 at 1:30 PM.

Based on the review of medical records and pertinent documentation, interviews with facility staff, a resident's family member, and third-party service providers, it was determined that the facility failed to provide and implement a revised plan of care to meet a resident's needs when the resident experienced seizures starting on 10/25/21 until the resident was sent to the hospital by Emergency Management Services (EMS) on 10/26/21 for [CONDITION(S)] management. The facility failed to: 1) Administer [MEDICATION(S)] to Resident (#1) as ordered by the Nurse Practitioner during an emergency medical situation on 10/25/21; 2) Monitor and notify the physician of a resident's worsening condition; and 3) Observe a hospice resident's wishes for life sustaining treatment as documented on the Maryland Orders for Life Sustaining Treatment (MOLST) form. This deficient practice was evident for 1 out of 14 residents (Resident #1) reviewed during the complaint survey and has the potential to impact all residents experiencing a medical emergency. Based on the findings, an Immediate Jeopardy (IJ) was identified on 11/05/21, at 4:30 PM. On 11/05/21 the facility presented plans to correct and remove the immediacy at 5:42 p.m., 7:38 p.m., 7:56 p.m., 9:19 p.m., 10:30 p.m., and 10:39 p.m. These plans were not accepted by the Office of Health Care Quality (OHCQ). The seventh plan of correction was presented at 11:02 p.m. and was accepted by the OHCQ. On 11/8/21 at 10:51 a.m. the facility presented an addendum to their abatement plan of correction regarding changing their proposed completion date from 11/10/21 to 11/11/21. An extended survey was completed at the facility on 11/09/2021 and 11/10/2021. On 11/12/21 at 2:45 p.m. after verification the removal plan had been implemented, the Immediate Jeopardy was abated. After removal of the immediacy the deficient practice remained with a potential for more than minimal harm and scope and severity of a D. The findings include: [MEDICATION(S)] is a medication used to treat a [CONDITION(S)]. According to the [CONDITION(S)] Foundation, this medication should be tapered, usually over weeks to months rather than abruptly stopped. Abrupt discontinuation of any Anticonvulsive may increase the risk of seizures. On 11/01/2021 a review of Resident #1's medical record revealed the following: Resident #1 was admitted to the nursing facility in August of 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the medical record Resident #1 was admitted to the facility, with medication orders that included [MEDICATION(S)] 1000 mg (milligrams) by mouth every 12 hours to treat a [CONDITION(S)] disorder. On 11/1/21 at 10:00 a.m. a review of Resident #1's medical record revealed that on 10/23/21 the resident was admitted to hospice services due to progressive decline and nutritional decline. These conditions were secondary to the resident's brain tumor diagnosis. According to the medical record at that time of admission to hospice services, a hospice physician (Physician #20) consulted with the resident's primary physician (Physician #21) before discontinuing several of Resident #1's medications. However, the hospice physician, Physician #20, did not discontinue the resident's order for [MEDICATION(S)]. Further review of Resident #1's record on 11/01/2021 revealed an order, with Nurse Practitioner (NP) #12's name as the licensed professional giving the order, to discontinue all of Resident #1's additional medications, including the order for [MEDICATION(S)], 1000 Mg (Milligrams) by mouth every 12 hours. There were no progress notes in the resident's record indicating why the medications were discontinued or instructions to monitor this resident for possible [CONDITION(S)] activity. On 11/1/21 a review of Resident #1's October 2021 Medication Administration Record (MAR) revealed the resident received the last dose of [MEDICATION(S)] on 10/24/21 during the 9:00 a.m. medication pass. On 11/1/21 a review of nursing progress notes revealed that on 10/25/21 at 3:47 a.m. LPN #24 documented the following regarding Resident #1: Received the client resting in bed. admitted under Hospice care day 2 and condition remains the same. Non-verbal and eyes are twitching and respond to tactile stimuli. Left outer arm peripheral line cannula removed at this time site without complications and pressure dressing applied. Incontinent care provided and care/comfort maintained. Will continue with POC. There were no other progress notes or assessments to document the resident's condition for the day until 12:35 p.m. that afternoon on 10/25/2021. On 11/1/21 further review of progress notes for Resident #1 revealed that on 10/25/21 at 12:35 p.m., NP #15 documented an encounter with the resident. NP #15 wrote, Seen at staff request. Unable to contact primary NP. The patient is seizing. The Hospice nurse was present in requesting medication orders. Orders were written for [MEDICATION(S)] and [MEDICATION(S)]. Full note to follow. Later, at 2:47 p.m., NP #15 documented the following, [Age and gender of the resident] on hospice seen at staff request for seizures. [Gender of the resident] has had a steady decline. [Gender of the resident] is no longer taking oral medications and they have been discontinued. The hospice nurse was present and had noted clonic seizures on the right side of the body and head. The patient is currently non-communicative. [Gender of the resident] saturations are adequate and [gender of the resident] is breathing without difficulty. On 11/1/21 at 1:00 p.m. A review of Resident #1's medication orders revealed that NP #15's order, dated 10/25/21 at 12:34 p.m. stated, administer [MEDICATION(S)] Concentrate 2 mg/ml- give 2 mg by mouth one time only for [CONDITION(S)] until 10/25/21 at [11:59 p.m.]. However, a second review of the resident's MAR on 11/02/2021 revealed the facility did not document the administration of [MEDICATION(S)] ([MEDICATION(S)]) on 10/25/21. According to the documentation on 10/25/21 a Unit Manager (LPN #13) initiated the MAR at 2:46 p.m. and coded the [MEDICATION(S)] medication as a five (5). A review of the MAR's code key revealed that a code of five means to withhold or not administer a medication. This indicated that Resident #1did not receive [MEDICATION(S)] as ordered at 2:46 p.m. that day. Resident #1's medical record revealed that on 10/25/2021 the resident's Maryland Medical Orders for Life-sustaining Treatment (MOLST) form was updated. The resident's MOLST form indicated the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review confirmed that this information was consistent with the Resident's wishes as documented on the previous MOLST form completed on 10/19/21. On 11/1/21 at 1:30 p.m. a review of a nurse's note by the Unit Manager (LPN #13) dated 10/26/21 at 11:51 a.m. documented that Resident #1 was noted shaking and jerking during the shift. [MEDICATION(S)] ([MEDICATION(S)]) and [MEDICATION(S)] were given. Resident #1's jerking decreased, but the resident was observed still having jerks and shakes. The hospice nurse evaluated the resident and recommended the resident be sent to ER for further elevation. Medical Director #25 was made aware of the resident's condition. Orders were provided to send the resident to the hospital via emergency services. On 11/5/21 a review of the Emergency Medical Run Sheet from Emergency Medical staff (EMS) dated 10/26/21 at 11:30 a.m. revealed that EMS staff reported arriving at the facility on 10/26/21 to retrieve a resident with a [CONDITION(S)]. RN#33 and one of Resident #1's family members advised EMS that the resident had seizures over a 24 hour period, and that the resident had not received [MEDICATION(S)] injection as ordered for [CONDITION(S)] management; however a facility nurse advised that the resident received [MEDICATION(S)] by mouth on 10/26/21 at 10:20 a.m. (before EMS arrived). EMS staff documented the following observation: Upon our arrival, pt (patient) had a twitch and was only responsive to painful stimuli. The facility nurse advised pt (patient) was administered [MEDICATION(S)] PO at 1020. Hospice staff wanted to be transferred to the emergency room for [CONDITION(S)] management. On 11/1/21 at 11:30 a.m., during an interview Physician #21, he stated he instructed NP #12 to discontinue Resident #1's [MEDICATION(S)] due to the resident having difficulty swallowing. On 11/1/21 at 12:00 p.m., a phone interview with the Unit 2 Manager (RN # 13) regarding Resident #1's care and the resident's [CONDITION(S)] activity on 10/25/21. LPN #13 stated that on 10/25/21 he was working on the unit passing medications and noticed that all of Resident #1's medications had been discontinued. He stated he was concerned because the resident was taking medication for seizures. LPN #13 stated he placed a call to the hospice provider to find out what was going on with Resident #1's medications. The Hospice Nurse, who had arrived at the facility during RN# 13's call, made LPN #13 aware that Resident #1 was having a [CONDITION(S)]. LPN #13 confirmed Resident #1 was having a [CONDITION(S)] when he entered the resident's room on 10/25/21. While LPN #13 was getting the medication the hospice nurse requested that the NP #15 evaluate Resident #1. NP #15 ordered stat (immediately) [MEDICATION(S)] 2mg IM (intramuscular, to be given by injection deep into the muscular tissue) and 5 mg of [MEDICATION(S)]. The [MEDICATION(S)] was administered on 10/25/21 at 12:00 p.m. and 2:00 p.m.; however, the pharmacy told LPN #13 that injectable [MEDICATION(S)] or [MEDICATION(S)] in pill form was not available in the facility's emergency box for administration. LPN #13 reported that when he went to retrieve the resident's [MEDICATION(S)], he noted that the emergency box did contain [MEDICATION(S)]; however, LPN #13 was unable to get the pharmacy to release the medication as the pharmacy's information showed the medication was not available in the facility emergency box. According to LPN #13 this information was reported to the DON on 10/25/21 prior to shift change. LPN #13 further stated that he requested that the pharmacy send the [MEDICATION(S)] to the facility Stat (immediately). According to LPN #13, the medication had not arrived before he left the facility at 3:00 p.m. LPN #13 reported that he told the evening nurse to look out for the medication and give it to Resident #1 when it arrived. This surveyor asked if the resident's physician was notified of the change in condition, he stated, No. On 11/2/21 at 10:30 a.m., in an interview, Pharmacist #17 stated that according to the carrier receipt sublingual (pill to be given under the tongue) [MEDICATION(S)] was sent to the facility on [DATE] and arrived that afternoon around 2:45 p.m. Pharmacist #17 also stated that [MEDICATION(S)] was not ordered IM (to be administered by intramuscular injection), it was ordered PO (to be administered by mouth), to be given by mouth. After checking the log sheet the pharmacist verified that the prescribed doses of [MEDICATION(S)], in both an injectable form and in pill form were listed on the Emergency Drug Kit Medications sheet, were in the facility Emergency Drug Kit and available for use on 10/25/21, the day [MEDICATION(S)] was ordered to treat Resident #1's [CONDITION(S)]. On 11/2/21 at 10:45 a.m. during an interview with NP #15 she stated that she evaluated Resident #1 on 10/25/21 because the hospice nurse could not get in touch with the NP #12, the NP that was assigned to the resident. She stated after giving medication orders for the resident, she proceeded to see her assigned resident(s). NP #15 stated she advised the nursing staff to contact her or the Resident #1's physician if the seizures continued. She stated she made the Director of Nursing (DON) aware of the issue with the emergency medication not being available on 10/25/21. On 11/2/21 at 1:00 p.m. during an interview with RN #33, (the hospice nurse that was present with Resident #1 on the afternoon of 10/25/21 and the morning of 10/26/21) revealed the following: RN #33 stated she went to see the Resident #1 at the facility on 10/25/21 at approximately 10:30 a.m. and the resident was actively seizing. The resident's pupils were fixed and dilated. She went to facility LPN #13 to address the seizing. LPN #13 reported to the hospice RN #33, that the facility's medical provider had discontinued the resident's orders for [MEDICATION(S)]. The facility had no plan in place to address the possibility of the resident having seizures after discontinuing the [MEDICATION(S)]. According to RN #33, the facility staff reported that they did not have adequate emergency meds in the facility to give the Resident #1. NP #15 ordered [MEDICATION(S)] to be given and the facility said they would have it by courier in two (2) hours. Hospice RN #33 stated on 10/25/21 the resident was seized for about 3 hours off and on. RN #33 also stated that she called the family of Resident #1 and when the family member arrived around 1:00 PM, the resident was still having seizures. When asked by this surveyor why the resident was not sent out to the hospital on 10/25/21, the hospice RN #33 stated that the facility stated the emergency [MEDICATION(S)] would be in the facility in two 2 hours. The hospice RN #33 stated she left the facility around 2:00 p.m. on 10/25/2021 and the medication had not arrived yet. The following day on 10/26/21 at approximately 10:00 a.m., the hospice RN #33 advised she returned to the facility and the resident was still seizing. The facility staff only had orders for [MEDICATION(S)] .5mg SL (sublingual, to be administered under the tongue) so she called 911 to transport the resident to the hospital where they treated the resident for seizures. Resident #1 did not return to the facility. Interview on 11/4/21 at 4:00 p.m. with Resident #1's family member (relative) revealed the relative arrived at the facility around 1:00 p.m. on 10/25/21. Upon arrival, Resident #1 was having a [CONDITION(S)]. The relative reported he/she was in and out of the facility all evening on 10/25/21 and that the facility staff never administered the resident anything for seizures that she observed. The relative went on to say he/she asked the facility's DON if the resident could be sent out to the hospital and the DON stated, We don't send hospice residents out to the hospital. The relative stated the resident was having seizures throughout the evening until the relative left at 9:00 p.m. on 10/25/2021. On 10/26/2021, the relative advised they arrived at the facility around 9:20 a.m. and an ambulance was outside. When the relative went to Resident #1's room, Resident #1 was observed having a [CONDITION(S)] and 911 was working with the resident. On 11/2/21 at 1:30 p.m. during an interview with NP #12 (the NP assigned to Resident #1), she denied discontinuing [MEDICATION(S)]. On 11/2/21 at 2:00 p.m. during an interview with the DON, she stated she thought Resident #1's seizures were resolved on 10/25/21. The DON stated, that NP #15 and LPN #13 made her aware that the STAT (immediate) medication [MEDICATION(S)] (IM or by mouth) was not available for Resident #1 in the facility's Emergency Drug Kit per the pharmacy. On 11/3/21 at 3:00 p.m. during an interview with RN #14, she stated the resident was having difficulty swallowing and she contacted the physician on 10/24/21 during the 3:00-11:00 PM shift to make him aware. She stated, Physician #21 gave an order to discontinue the resident medications. She stated she did not ask the physician about the [MEDICATION(S)], and he did not mention it. On 11/4/21 at 3:00 p.m. during an interview with the LPN #16 (the nurse that worked 3:00 a.m-11:00 p.m. on 10/25/21) when asked why the [MEDICATION(S)] as ordered by the NP #15 was not administered to Resident #1 after the medication arrived from the pharmacy on 10/25/2021. LPN #16 stated she never saw the medication, and during the change of shift report at 3:00 p.m. on 10/25/21, LPN #13 did not report to her that Resident #1 had a [CONDITION(S)] during the 7:00-3:00 p.m. shift on 10/25/2021. On 11/4/21 at 3:30 p.m. during an interview with the DON, she was asked if any education and/or in-services were done with staff after this incident with Resident #1. The DON stated, no, I thought the issue was resolved. Based on the findings, an Immediate Jeopardy (IJ) was identified on 11/05/21, at 4:30 PM. On 11/05/21 the facility presented plans to correct and remove the immediacy at 5:42 p.m., 7:38 p.m., 7:56 p.m., 9:19 p.m., 10:30 p.m., and 10:39 p.m. These plans were not accepted by the Office of Health Care Quality (OHCQ). The seventh plan of correction was presented at 11:02 p.m. and was accepted by the OHCQ. On 11/8/21 at 10:51 a.m. the facility presented an addendum to their abatement plan of correction regarding changing their proposed completion date from 11/10/21 to 11/11/21. An extended survey was completed at the facility on 11/09/2021 and 11/10/2021. On 11/12/21 at 2:45 p.m. after verification the removal plan had been implemented, the Immediate Jeopardy was abated. After removal of the immediacy the deficient practice remained with a potential for more than minimal harm and scope and severity of a D. The Facility's Immediate Jeopardy abatement plan included the infromation below. Immediate Corrective Action: 1. Resident #1 is no longer at the facility. The facility is unable to retroactively revise the care plan. 2. Director of Nursing (DON) suspended for failure to intervene with pharmacy discrepancy and further action pending up to and including termination. The Clinical Director of Nursing Services is the Interim Director of Nursing. 3. The Director of Nursing/Designee reviewed all discontinued medications to identify the need for additional medications. 4. Pharmacy has corrected the error in their programming and reconciled the emergency medication box to ensure that all medications included in the box are listed in their electronic database on 11/4/21. 5. Interim DON immediately initiated the following education to licensed nurses on 11/4/21 to be completed by 11/11/21 with ongoing monitoring, licensed nurses will not be permitted to work until education has been completed. a. Unavailable medication policy reviewed which highlights what to do if medication ordered is unavailable per practitioner order. b. Change in Condition policy reviewed with physician notification of any acute changes. c. Documentation policy reviewed specific to worsening conditions. d. Care plan policy reviewed to ensure revision and development of a plan of care with changes in condition. 6. The Medical Director provided education to the practitioners (physician and CRNP) on 11/4/21. a. Tapering of [MEDICATION(S)] medication and completing documentation on discontinued medications. The Medical Director will in-service all practitioners on monitoring critical medications to be completed by 11/9/21. Identification of others with the potential to be affected: 1. All residents receiving medication have the potential to be affected by deficient practices. 2. The DON/Designee immediately reviewed medication orders received due to emergent medical conditions for the past seven (7) days to ensure administration per practitioner order. 3. Resident progress notes for the past seven (7) days were reviewed to ensure that any emergent change in condition is being monitored and physician notification has occurred, as needed. 4. Care plans reviewed and revised for residents with [CONDITION(S)] diagnosis. 5. Reviewed all hospice residents to ensure that PRN [MEDICATION(S)] and [MEDICATION(S)] are available. Systemic Change to be implemented 1. DON/Designee will educate licensed nurses on the procedure to validate that all medications are provided through the 24-chart check procedure. Education will be completed before the scheduled shift, new hire orientation, and annually. Nurses will not assume assignments until education has been completed. 2.The medication emergency box will be audited with medication addition and/or deletion weekly for 4 weeks then monthly for 3 months. Licensed nursing staff educated of contents with all additions and/or deletions weekly for 4 weeks then monthly for 3 months. 3. Review of unavailable medications will be completed by the next shift and noted on the 24-hour report for further review by the DON/designee. 4.Hospice orders will be reviewed by the interdisciplinary team during the daily clinical meeting to ensure compliance weekly for 4 weeks then monthly for 3 months. 5. DON/Designee will review the emergent change in condition plan of care daily during the clinical meeting and revise as needed weekly for 4 weeks then monthly for 3 months. Monitoring 1. Randomly audit ten (10) residents per week for 4 weeks then monthly for 3 months to ensure that medications are administered per practitioner order. Results will be discussed at the QAPI committee meeting for recommendations until substantial compliance is achieved. 2. Randomly audit ten (10) resident charts weekly for 4 weeks then monthly for 3 months to ensure physician notification of worsening conditions. Results will be discussed at the QAPI committee meeting for recommendations until substantial compliance is achieved. 3. Randomly audit ten (10) resident charts weekly for 4 weeks then monthly for 3 months to ensure continued monitoring of worsening conditions is documented in the medical records. Results will be discussed at the QAPI committee meeting for recommendations until substantial compliance is achieved. 4. Randomly audit ten (10) resident charts weekly for 4 weeks then monthly for 3 months to ensure that care plans are implemented and revised to meet the resident needs with emergent changes in conditions. Results will be discussed at the QAPI committee meeting for recommendations until substantial compliance is achieved. The facility alleges compliance with the abatement plan as of 11/11/21.

Based on medical record review, observation of facility video surveillance and interview, the facility staff failed to prevent a resident from being abused (Resident #34). This was evident for 1 out of 36 residents reviewed during a complaint survey. This incident resulted in actual physical harm (pain) to the resident. Due to the facility's corrective measures following the incident, this is being cited as past non-compliance with a compliance date of 3/12/21. The findings include: On 3/15/21 a review of facility reported incident MD 534 revealed the facility submitted a report on 3/4/21 to OHCQ (Office of Health Care Quality) that on 3/4/21 Resident #34 reported he/she was physically abused by LPN #1. The resident reported to the OT (Occupational Therapist) #1 during night shift on 3/4/21 he/she was hit by LPN #1 in the hallway and forcefully pushed his/her wheelchair in his/her room into his/her bed. A Review of Resident #34's medical record on 3/15/21 and 3/16/21 revealed the resident was admitted to the facility on [DATE] from the hospital for rehabilitation. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #34's medical record revealed a nurse's note on 3/4/21 at 4:28 PM stating the resident was assessed and found to have no injury. During interview with the Administrator on 3/15/21 at 1:00 PM the Administrator stated on 3/4/21 when the Resident advised OT #1 of the alleged abuse the facility staff began the investigation. The Administrator stated she viewed the video from 3/4/21 and could confirm LPN #1 threw an object twice and hit the Resident's back on 3/4/21 night shift. The Administrator stated LPN #1 has been fired and reported to the Maryland Board of Nursing on 3/10/21. The surveyor then watched the video with the Administrator on 3/15/21 at 1:00 PM. In the video Resident #34 is seen throwing an object in the direction of the LPN #1. LPN #1 is then seen throwing an object twice hitting Resident #34 in the back two times. Interview with the Administrator at that time confirmed LPN #1 is seen in the video throwing an object twice and hitting Resident #34 in the back two times. On 3/15/21 a review of Resident #34's care plans revealed a care plan entitled I have a behavior problem related to throwing feces on the floor, throwing cans at staff and refusal of care that was initiated on 2/22/21. The care plan included the following intervention: Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. During interview with Resident #34 on 3/16/21 at 9:45 AM, when asked if he/she remembered an incident that happened recently, he/she stated, I was mad because he (LPN #1) had not given me my pain medication, so I picked up 2 containers and threw it in his (LPN #1) direction. I did not hit him. Then he started hitting me and picked up a bottle and hit me with it. He then took me by my wheelchair and pushed me into my room. The resident was asked by the surveyor how he/she felt after the incident, the resident stated, When he was hitting me, I felt threatened. The surveyor asked the resident if he/she experienced any pain at the time of the incident. The resident stated yes. The surveyor asked if he/she could rate the pain on a scale of 1 to 10. The resident stated yes, he/she was in pain and would rate the pain as a 5 to 6 out of 10. During interview with the Administrator on 3/15/21 at 1:00 PM, the Administrator confirmed the facility substantiated abuse by LPN #1 against Resident #34 on 3/4/21. A review on 3/18/21 of the facility response to the incident revealed: 1. The facility in-serviced staff on 3/4/21 through 3/12/21 on the topic of abuse policies and procedures. 2. The facility held a Quality Assurance Performance Improvement (QAPI) meeting on 3/4/21 with the topic: To provide residents a safe environment free from abuse and neglect. 3. Facility reported LPN #1 to the Maryland Board of Nursing on 3/10/21. 4. Facility placed LPN #1 on administrative leave on 3/4/21 and following the investigation, terminated LPN #1 on 3/10/21. 5. Facility reported the incident to the state agency on 3/4/21. As a result of the facility's corrective measures in response to the incident, with a compliance date of 3/12/21, this deficiency is cited as past non-compliance. Cross reference F 603

Based on medical record review, observation of facility video surveillance and interview, the facility staff failed to prevent a resident from being placed in involuntary seclusion (Resident #34). This was evident for 1 out of 36 residents reviewed during a complaint survey. This incident resulted in actual psychological harm to the resident. Due to the facility's corrective measures following the incident, this is being cited as past non-compliance with a compliance date of 3/12/21. The findings include: On 3/15/21 a review of facility reported incident MD 534 revealed the facility submitted a report on 3/4/21 to OHCQ (Office of Health Care Quality) that on 3/4/21 Resident #34 reported he/she was physically abused by LPN #1. The Resident reported to the OT (Occupational Therapist) #1 during night shift on 3/4/21 he/she was hit by LPN #1 in the hallway and forcefully pushed his/her wheelchair in his/her room into his/her bed. A review of Resident #34's medical record on 3/15/21 and 3/16/21 revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview with the Administrator on 3/15/21 at 1:00 PM the Administrator stated on 3/4/21 when the Resident advised OT #1 of the alleged abuse the facility staff began the investigation. The Administrator stated she viewed the video from 3/4/21 and could confirm LPN #1 threw an object twice and hit the Resident's back on 3/4/21 night shift. The Administrator stated LPN #1 has been fired and reported to the Maryland Board of Nursing on 3/10/21. The surveyor then watched the video with the Administrator on 3/15/21 at 1:00 PM. In the video Resident #34 is seen throwing an object in the direction of the LPN #1. LPN #1 is then seen throwing an object twice hitting Resident #34 in the back two times. Interview with the Administrator at that time confirmed LPN #1 is seen in the video throwing an object twice and hitting Resident #34 in the back two times. While watching the video with the Administrator on 3/15/21 at 1:00 PM, LPN #1 is then seen pushing Resident #34 back to his/her room in his/her wheelchair by tilting the resident on the back two wheels. In the video, the resident is heard screaming as LPN #1 is seen pushing the resident while leaning back on two wheels down the hall. LPN #1 is seen exiting the room and holding the resident's door closed. Then GNA #1 is seen in the video walking down the hallway to Resident #34's room and relieves LPN #1 from holding the door. GNA #1 holds door closed while LPN #1 is seen getting medication from the medication cart. LPN #1 is then seen going back to Resident #34's room with medication. During interview with Administrator at the time, the Administrator stated the facility fired GNA #1 for holding the Resident's door closed and reported GNA #1 to the Board of Nursing on 3/10/21. During interview with Resident #34 at 9:45 AM, Resident #34 stated when LPN #1 pushed him/her in his/her room, he/she was trying to get out of his/her room, but LPN #1 was holding the door shut. The surveyor asked the Resident how he/she felt at that moment of being pushed into his/her room and not being able to leave, the Resident stated he/she was in fear of what was going to happen next. During interview with GNA #1 on 3/18/21 at 10:04 AM via phone, GNA #1 stated Resident #34 was yelling and cursing about not receiving his/her pain medication. GNA #1 also stated the Resident was throwing things and tried to grab at LPN #1's computer. GNA #1 stated LPN #1 then wheeled the Resident back to his/her room and then held the Resident's door shut. GNA #1 stated LPN #1 asked GNA #1 to stand by the door so GNA #1 went to the Resident's door and held the door shut. The surveyor asked GNA #1 what the Resident was doing at the time, GNA #1 stated the Resident was cursing, saying he/she couldn't get out and was trying to open the door. GNA #1 stated she was holding the door shut for approximately 2 minutes when LPN #1 came back with medication for the Resident. Interview with the Administrator on 3/15/21 at 1:00 PM confirmed the facility staff failed to protect Resident #34 from involuntary seclusion. A review on 3/18/21 of the facility's response to the incident revealed: 1. The facility in-serviced staff on 3/4/21 through 3/12/21 on the topic of abuse policies and procedures. 2. The facility held a Quality Assurance Performance Improvement (QAPI) meeting on 3/4/21 with the topic: To provide residents a safe environment free from abuse and neglect. 3. Facility reported LPN #1 and GNA #1 to the Maryland Board of Nursing on 3/10/21. 4. Facility placed LPN #1 and GNA #1 on administrative leave on 3/4/21 and following the investigation, terminated LPN #1 and GNA #1 on 3/10/21. 5. Facility reported the incident to the State Agency on 3/4/21. As a result of the facility's corrective measures in response to the incident, with a compliance date of 3/12/21, this deficiency is cited as past non-compliance. Cross Reference F 600

Based on medical record review, staff and family interviews it was determined the facility involuntarily secluded an alert and oriented resident (#9) for 19 days (from 7/13/15 through 8/1/13) when he/she stated he/she wanted to leave the facility. This was evident for 1 of 2 residents identified during a review of complaint #MD 037.These failures resulted in an immediate jeopardy being identified on August 28, 2015 at 2:00 PM related to an alert and oriented resident (#9) being placed on a second floor unit, that would not allow her/him the ability to exit without permission due to the implementation of a WanderGuard bracelet. The Office of Health Care Quality accepted the facility plan to remove immediacy at 7:40 PM on August 28, 2015 while on site. After removal of the immediacy, the deficient practice continued with the potential for more than minimal harm with a scope/severity of E level for the remaining residents. The findings include:Resident #9 was admitted to the nursing home in July 2015 for rehabilitation following hospitalization to treat [MEDICATION NAME] toxicity. [MEDICATION NAME] toxicity is having high levels of [MEDICATION NAME] in the blood that can cause side effects such as confusion, drowsiness, dizziness, lack of coordination, nausea, vomiting, decreased appetite or coma. The resident also had a history of [REDACTED].Two days after admission Resident #9 was deemed an elopement risk and was placed on 1:1 observation, a Wander Guard bracelet was placed on the resident's ankle and he/she was moved to a second floor unit. A nursing progress note dated 7/13/15 at 1:12 PM reported the resident, states he/she will go home today and was seen ambulating around the unit from time to time. A progress note dated 7/13/15 at 6:22 PM documented the resident would be transferred to the second floor. The progress note did not describe any behavior that might have warranted consideration of the aforementioned interventions.The admission MDS assessment completed on 7/18/15 triggered for behavioral symptoms. Section E Behavior E0900 indicated the resident was coded for wandering. In Section E1000 Wandering Impact the resident was coded as not being at significant risk of getting to a potentially dangerous place such as the stairs or outside of the facility and it was noted that the wandering did not intrude on the privacy of others. Section E0200 Behavioral Symptoms indicated there were no behaviors (hitting, kicking, threatening, screaming, rummaging, disrobing, etc.) exhibited.Medical record review failed to reveal an elopement risk assessment or an individualized care plan to support moving the resident to a more restrictive environment. The MDS care area assessment dated [DATE] stated the resident, wandered the hallways on his/her first night as he/she was not used to the new environment.During an interview with the Unit Manager on 8/27/15 at 8:20 AM, he/she stated the second floor was more secure for individuals at risk for elopement. He/she explained that although the doors on the first floor alarm when an individual wearing a bracelet approaches the door, the doors can be opened by leaning on them for a specified period of time (necessary to meet fire safety codes). On 8/28/15 the surveyors requested a copy of the facility's elopement policy and procedure and were presented with an information sheet from a larger reference document. The document submitted as the facility policy revealed the expectation that an elopement risk assessment would be conducted for all new admissions. Despite the policy, in interview at approximately 12:30 PM on 8/28/15, the Director of Nursing stated to the survey team that the facility did not conduct elopement risk assessments on admission.On 8/28/15, during survey investigation, in interview with the Administrator, he/she described Resident #9 as being at high risk for elopement and indicated that the restriction was necessary to keep the resident safe. He/she stated Resident #9 packed his/her bags and stood at the door wanting to leave the building and he/she indicated that Resident #9 repeatedly stated the desire to go home. The administrator stated that this was why Resident #9 was restricted to the second floor unit with the Wander Guard system in place. These observations were not documented in the resident's medical record and the content of the care plan did not indicate the Assessment Coordinator had knowledge of this information. Resident #9 was alert and oriented, was able to make his/her own needs known and was not certified as lacking decision-making capacity. Therefore, Resident #9 had the right to leave the facility. Instead, Resident #9 was moved to the restrictive second floor unit until discharge and involuntarily secluded for 19 days; and until 5 days before discharge (total of 13 days) the resident was also subjected to 24/7 staff supervision.On August 28, 2015 an Immediate Jeopardy was called at 2:00 PM related to a WanderGuard bracelet being placed on Resident #9 and the resident being confined to a unit for alleged wandering behaviors, when there was no documentation of the need for such intervention. The Office of Health Care Quality accepted the facility plan to remove immediacy at 7:40 PM on August 28, 2015 while on site. Steps taken by the facility to remove the immediacy included, but were not limited to: an audit of those residents with security bracelets to assess the compliance with the Wander Practice guidelines, education of staff on the alert bracelet and secured unit guidelines, and Quality Assurance monitoring plan. Cross reference F272

Based on interviews with staff, residents and family, and review of medical records, policies, procedures and other (hospital) documentation, it was determined that facility failed to meet the individualized needs of residents when: 1) Resident #74 was sent to the hospital Emergency Department (ED) in error for services that she/he was not intended to receive, causing emotional harm; 2) Resident #9, the intended recipient of the ED services, was not transported to the hospital even after the discovery that the wrong resident had been sent; 3) the facility failed to conduct an investigation into how Resident #74 was sent to the ED, instead of Resident #9, and failed to implement a plan to address the concerns; 4) an alert and oriented Resident (#9) with capacity to make his/her own decisions was involuntarily secluded to a restricted unit for 19 days (7/13/17 through 8/1/15), against his/her will with the rationale that the facility was keeping the resident safe and these restrictions were instituted without any documented assessment, were instituted without any documented behaviors to support the intervention, and were maintained contrary to the care plan; and 5) failure to implement recommendations related to medication management (residents #16, and #53). Theses concerns were evident for 4 of 55 residents (#74, #9, #16 and #53) reviewed during this survey.These failures regarding Resident #74 being sent to the hospital for psychiatric evaluation in error, and Resident #9 being placed on a WanderGuard and being confined to a unit for wandering when there was no documentation of the need for such intervention, resulted in an immediate jeopardy being identified on August 28, 2015 at 2:00 PM. A plan to remove the immediacy was submitted to the survey team on 8/28/15 and accepted at 7:40 PM. After removal of the immediacy, the deficient practice continued at the potential for more than minimal harm with a scope/severity of E level for the remaining residents. Cross reference F272 (Residents #74 and #9)The findings include: 1. Resident #74 was admitted to the facility in June 2007 and presented as alert and oriented and able to make his/her needs known. The most recent comprehensive MDS assessment (reference date 6/27/15) revealed that the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14 out of 15 in Section C (Cognitive Patterns) for the assessment period of 6/21/15 through 6/27/15). The BIMS is an assessment that assists staff in determining a resident's cognitive understanding and the score of 14 indicated that the resident was cognitively intact. A BIMS score of 13-15 indicates that a resident is cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment.Staff and family interviews and review of a 7/21/15 hospital ED record revealed that Resident #74 was sent to a hospital ED for a psychiatric evaluation on 7/21/15 and then staff determined that Resident #74 had been sent in error. Review of an entry in the hospital ED record dated 7/21/15 at 3:28 PM revealed documentation that nursing home staff called the hospital and informed the hospital nurse that they mistakenly sent Resident #74 and that the error occurred because there was another resident in the nursing home with the same last name (Resident #9). The hospital record also documented that the resident had stated that she/he was not aware of the reason why she/he had been sent until after she/he had arrived at the hospital.In an interview with Resident #74 on 8/27/15 at 10:55 AM, he/she stated that the nursing home nurse told her/him that she/he had an appointment at 2:30 PM to go to the hospital. In an interview with family member #1 on 8/28/15 at 10:57 AM, she/he indicated that she/he received a call informing her/him that the nursing home was sending her/his mother to the hospital for a psychiatric evaluation. The family member stated that during that call, she/he questioned the nursing home staff and told them that there was no reason for the resident to have a psychiatric evaluation and nothing was wrong with the resident. Nonetheless, without consent of the resident or the family, Resident #74 was sent to a local ED for a psychiatric evaluation that was not ordered and was not necessary.During an interview, the resident stated that upon arrival to the hospital she/he was told the appointment was for a psychiatric evaluation, and was later told by the hospital nurse that the nursing home facility had sent the wrong resident. A family member came to the hospital and transported the resident back to the nursing home. The resident reported to the surveyor that she/he was so upset about being sent out for a psychiatric evaluation that it was difficult for her/him to even talk about it. During an interview with GNA #1 on 8/28/15, he/she corroborated that the Resident #74 had told her that they were upset from having been sent to the ED in error. When asked who the GNA told about the reported concern, she stated that she assumed everyone already knew, and added that this was a concern with/for day shift. During an interview with the unit manager on 8/27/15 at 12:03 PM and on 8/28/15 at 9:03 AM, he stated that he thought the physician wanted to send Resident #74 to the hospital because she/he was not eating well, was losing weight and that there was concern this might indicate depression. However, review of the MDS, specifically, in Section K (Swallowing and Nutritional Status) Item K0300, facility staff coded that Resident #74 was actually on a prescribed physician's weight loss regimen. Further, the weight loss concern for Resident #74 that the unit manager had noted, was not a new symptom and therefore would not have ordinarily generated any great alarm. Review of the Nutrition assessment dated [DATE] reported that the resident had a significant weight loss of 31 pounds over the prior 180 days. This assessment from the dietitian confirmed that the weight loss was expected and noted that contributing factors included resolving [MEDICAL CONDITION] (swelling from retained fluids), and the prescribed physician weight loss regimen. Also, review of the coding in Section D (Mood), revealed no symptoms of depression. Nonetheless, the unit manager indicated that Resident #74 was sent out with an understanding that she/he was not eating well and was losing weight and therefore the resident could have been depressed.During an interview on 8/27/15 at 3:24 PM, the physician stated that he ordered to send Resident #9 to the hospital. He stated that he never would have authorized sending Resident #74 because his/her needs could have been met in the nursing home and that there was not sufficient clinical reason to send her/him to a hospital ED. Interview with Resident #74 on 8/27/15 at 10:55 AM, interview with family member #1 on 8/27/15 at 11:23 AM, and interview with family member #2 on 8/28/15 at 11:55 AM, all corroborated that resident #74 did not understand why she/he was sent to the hospital and that the resident was very upset once she/he learned at the hospital that she/he was there for a psychiatric evaluation. No documentation of this adverse event could be found the medical records for Resident #9 or Resident #74. Review of the facility transfer log revealed that the transfer was not recorded there as would ordinarily have been done for any transfer. In interview on 8/28/15, senior staff reported that no incident report was filed by any staff aware of the transfer error as would normally be done for an unusual incident.In interview/conference with facility management staff on 8/28/15, the Administrator reported that she did recall discussing a transfer to the ED for Resident #9 in their morning Eagle Room meeting but she did not recall the details. When asked for minutes of this meeting on 8/28/15 at approximately 12:30 PM, the Administrator stated that documentation from these meetings are destroyed every month. On 8/28/15, during an interview with the DON and senior QA Consulting staff, they reported to the survey team that until the survey team brought it to their attention, they were both unaware of the even having taken place. In addition to the psychosocial harm, Resident #74 could well have been held against her/his will in the hospital for an extended period of time for the psychiatric evaluation without any reasonable clinical justification.2. Resident #9 was admitted to the facility on [DATE]. The admission MDS assessment (assessment reference date 7/18/15) and a quarterly MDS assessment (assessment reference date of 7/31/15) revealed that Resident #9 was assessed with [REDACTED]. The BIMS is an assessment that assists staff in determining a resident's cognitive understanding and the score of 14 indicated that the resident was cognitively intact. A BIMS score of 13-15 indicates that a resident is cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. The admission MDS screening also corroborated (in section B at items B0700 and B0800) that Resident #9 was usually able to understand others and was usually able to make herself/himself understood. Coding in section E (Behavior) MDS item E0900 indicated that Resident #9 had exhibited signs and symptoms of wandering behavior. When completed, the Admission MDS screening identified the need for the Care Area Assessment (CAA) regarding the coded behavioral concern.The process for Admission Assessments requires that the screening, the CAA and the care plans are all complete by day 14 of the admission. For Resident #9, day 14 was 7/24/15. However, the assessment staff did not complete the screening or trigger the care areas until 7/29/15. Even then, no evidence was found that the required CAA was ever completed. When it was completed, the MDS care area assessment worksheet documented only that the resident, wandered the hallways on his/her first night as she/he was not used to the new environment. This single restatement of one observation was not a comprehensive assessment and provided no objective measures upon which to base a care plan for elopement risk. In an interview with the physician on 8/27/15 at 3:25 PM, the physician stated that she/he gave a verbal order to send Resident #9 out to the hospital for a psychiatric evaluation on 7/21/15. No documentation of any behaviors supported this plan. Additionally, with an apparent miscommunication between the unit manager and the physician, and without a clear understanding of Resident #74's actual needs, staff entered the verbal order for Resident #9 into the record for Resident #74 and then sent Resident #74 to the hospital in error. On 8/27/15, the surveyor reviewed an entry in the hospital ED record dated 7/21/15 at 3:28 p.m. that revealed nursing home staff had called the hospital and informed the nurse that they sent the wrong resident (Resident #74) to the hospital for the psychiatric evaluation and that the error occurred because there was another resident in the facility with the same last name (Resident #9).During an interview with the surveyor on 8/27/15 at 3:55 PM, the physician reported that when she/he later signed off the verbal order to send Resident #9 to the hospital for a psychiatric evaluation, he did not review all of the verbal orders prior to approving them. The physician stated that in the electronic system all of the orders come up together and they all are signed off with one click. Therefore, he did not realize that the order had been entered in the wrong resident's record (Resident #74).After facility staff contacted the hospital and had Resident #74 sent back from the hospital, no staff ever updated Resident #9's record with the order, no required notifications were made about the error, and no incident report was filed regarding the failure to send Resident #9 to the hospital after obtaining the order. No updates were found regarding the event in Resident #9's care plans. In addition to these failures to document the error not sending resident #9 out when the order had been obtained, interviews and review of record documentation revealed that in fact, no staff ever sent Resident #9 out for the ordered psychiatric evaluation. In interview with the attending physician on 8/28/15, he reported that he saw Resident #9 two days after the mix up and felt that Resident #9 was actually stable enough to not be sent out. When asked what follow up he did and to whom he reported the incident, he stated that he decided to just let it go.Although the physician, multiple staff, family, and hospital staff were aware that the wrong resident (Resident #74) was sent to the ED for a psychiatric evaluation, neither of the adverse events (sending Resident #74 and not sending Resident #9) was found documented anywhere. In interview on 8/28/15, both the DON and the facility QA Consultant reported that at the time of the survey, they still did not even know about these two serious adverse events. Resident #9 was discharged in August 2015 and she/he had never received the ordered hospital psychiatric evaluation and was also never seen by behavioral health services in the facility. At the time of the survey, the facility had not investigated the event, and had not developed any plans to ensure such an event might not occur again in the future. 3. An alert and oriented resident (#9) was involuntarily secluded to a secure unit for 19 days with multiple interventions intended to restrict her/his freedom of movement after she/he had repeatedly expressed the desire to leave the facility.Resident #9 was admitted to the facility on [DATE]. The admission MDS assessment (assessment reference date 7/18/15) and a quarterly MDS assessment (assessment reference date of 7/31/15) revealed that the resident was assessed with [REDACTED]. The BIMS is an assessment that assists staff in determining a resident's cognitive understanding. A BIMS score of 13-15 indicates that a resident is cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment.The admission MDS screening also corroborated (in section B at items B0700 and B0800) that Resident #9 usually was able to understand others and usually was able to make herself/himself understood.In review of the medical record on 8/27/15, no certifications were found documented in the record indicating that Resident #9 could not make his/her own decisions. In interview with the social worker on 9/4/15 at 10:59 AM, the social worker confirmed that there were no certifications demonstrating that Resident #9 was unable to make her/his own decisions. She added that Resident #9 was alert, oriented, and able to make his/her needs known. In the MDS Admission screening, coding in section E (Behavior) MDS item E0900 indicated that Resident #9 had been coded with signs and symptoms of wandering behavior. When completed late on 7/29/15, the Admission MDS screening triggered (identified the need for) the CAA (Care Area Assessment) regarding the coded behavioral concern. Under standards of practice, an objective elopement assessment should have been conducted prior to instituting elopement interventions that restricted Resident #9's freedom of choice and movement. Further, by facility policy, an objective assessment of elopement risk should have been conducted when Resident #9 was first admitted . When asked by the survey team on 8/28/15 for the facility policy on managing elopement risk, the Administrator provided a one page information sheet. Twice on 8/28/15, the Administrator stated that the document provided was the facility policy. The policy sheet (from a larger reference document) contained a header at the top of the page entitled, Phase 1: Assess (CONT) defined and described elopement. Guidance from the policy was limited but did reveal that there was an expectation that an elopement risk assessment would be conducted for all new admissions. In a statement with no defined exclusions, the policy sheet indicated that patients are evaluated upon admission for a history of, or risk factors for wandering and, or exit seeking. Despite this policy statement, in interview at approximately 12:30 PM on 8/28/15, the Director of Nursing stated that the facility actually did not conduct any elopement risk assessments for residents on admission. Review of the medical record for Resident #9 revealed that two days after admission with no elopement risk assessment conducted, staff deemed her/him an elopement risk. On or by this same date multiple restrictive measures were implemented. A WanderGuard bracelet was placed on the resident's ankle, the resident was placed on one to one supervision, and she/he was moved to the restrictive second floor unit. A nursing progress note dated 7/13/15 at 1:12 PM documented that the resident stated she/he will go home today and was seen ambulating around the unit from time to time. A progress note entered later that same day at 6:22 PM indicated that the resident would be transferred to the second floor. During an interview with the Unit Manager on 8/27/15 at 8:20 AM, he stated the second floor was more secure for individuals at risk for elopement and he indicated that staff were keeping Resident #9 safe. In interview on 8/28/15, the Administrator also described Resident #9 as being at high risk for elopement and indicated that the restrictions were necessary to keep the resident safe. She stated that Resident #9 had packed her/his bags and stood at the door wanting to leave the building and she indicated that Resident #9 had repeatedly stated the desire to go home. However, this observation was not found documented anywhere. Review of the medical record revealed that no documented resident behaviors supported the combined interventions of the WanderGuard, the second floor placement, and one to one staffing. No clinical notes were found describing any behaviors that might have supported consideration of the combined interventions. Further, four MDS screening assessments covering the entire period from 7/12/15 through the end of the resident admission on 8/1/15, documented that in fact there were no actual behaviors that supported the combined interventions that staff had implemented. Further, in interview with the Administrator, Director of Nursing (DON) and Quality Assurance (QA) Consultant on 8/28/15, both the DON and Administrator indicated that, by policy, no staff providing one to one staffing with a resident ever document resident behaviors anywhere. By policy, the DON and Administrator stated that these staff members only report behavioral concerns to the assigned nurse verbally. The failure to ensure that staff timely document the actual observations of resident behavior(s), for this resident already placed on extreme restrictions, meant that no-one on the interdisciplinary team had important information to evaluate the effectiveness and appropriateness of those very interventions, yet the restrictive interventions continued for weeks.Later on 7/29/15, when the resident specific MDS screening identified this resident at particular risk and triggered the behavioral care area for comprehensive assessment, staff still did not conduct an objective and comprehensive assessment of elopement risk for Resident #9. In the admission MDS assessment with reference date of 7/18/15, coding in section E (Behavior) Item E0900 indicated the resident was coded for wandering and when the screening was completed the MDS triggered for behavioral symptoms. Under the mandated care process, the facility was then required to conduct a comprehensive assessment of this care area by day 14 of admission to ensure that care plans guided care to meet the real needs of the resident. However, the MDS CAA worksheet only stated that the resident wandered the hallways on his/her first night as she/he was not used to the new environment. This one restatement of one observation was not an objective and comprehensive assessment of/for Resident #9. Thus even on 7/29/15, nearly three weeks after the combined restrictive measures had been implemented, no legitimate CAA was conducted. A care plan for elopement risk was generated for Resident #9 on 7/14/15, three days after admission and one day after the resident had been moved to the second floor against his/her will. No evidence was found indicating the care plan was ever again updated.With no assessment to base it upon, when developed, the care plan also did not reflect all of the interventions that were already implemented by staff the day before the plan had been created. The planned interventions documented in the care plan included only: calmly redirecting the resident to an appropriate area; checking for presence and function of alert bracelet every shift; educating family and visitors to advise staff when leaving the patient following visit; encouraging socialization with others, providing recreational programming; and last, removing items that may trigger attempt to leave facility (i.e. boots, coats .). Interviews with senior staff on 8/28/15 revealed that the facility second floor elevator locked down when anyone wearing the WanderGuard approached so that no-one with a WanderGuard could leave the unit. Thus with combined interventions, Resident #9 was placed on the WanderGuard system, moved to the second floor behind the locking elevator, and placed on 24/7 one to one staff supervision. The 24/7 supervision ended on 7/26/15 but the resident remained secluded to the secure unit until 8/1/15 (a total of 19 days). The intent and the effect of these interventions was that Resident #9 could not leave the restricted second floor unit without direct staff assistance and supervision, and Resident #9 could not leave the facility at all. These failures regarding Resident #74 being sent to the hospital for psychiatric evaluation in error, and Resident #9 being placed on a WanderGuard and being confined to a unit for wandering when there was no documentation of the need for such intervention, resulted in an immediate jeopardy being identified on August 28, 2015 at 2:00 PM. A plan to remove the immediacy was submitted to the survey team on 8/28/15 and accepted at 7:40 PM.Steps taken by the facility to remove the immediacy included, but were not limited to: an audit of those residents with security bracelets to assess the compliance with the Wander Practice guidelines, education of staff on the alert bracelet and secured unit guidelines, an audit of those residents with like names to ensure those charts had alert stickers, audit in-service of staff on verbal orders and acute setting transfers, and a Quality Assurance monitoring plan. 4. On 9/2/15 review of Resident #16's medical record revealed that the resident was currently receiving [MEDICATION NAME] Acid 500 mg two times a day for [MEDICAL CONDITION] and had been receiving this dose since 8/4/15. Further review revealed that on 8/14/15 the pharmacist had recommended monitoring the [MEDICATION NAME] acid level on next lab day, and on 8/17/15 the nurse practitioner accepted the recommendation and requested the recommendation be implemented as written. This signed pharmacy recommendation for the [MEDICATION NAME] acid level was found in the active chart located on the nursing unit. On 9/2/15 at 4:15 PM the nurse (staff #12) reported that all orders are entered into the computer by nursing, either verbal or hand written. In regard to the pharmacy recommendation sheet for this resident, the nurse reported that it was an order that they would implement in the computer. The nurse then attempted to find the order for the [MEDICATION NAME] Acid level on the computer and was unable to do so. On 9/2/15 further review of the medical record failed to reveal any results of a [MEDICATION NAME] acid level for August or September 2015. Review of the electronic health record failed to reveal an order for [REDACTED]. On 9/3/15 at 11:42 AM surveyor discussed the above information with the Director of Nursing (DON) and requested any [MEDICATION NAME] acid level drawn as a result of the 8/17/15 order. It is important to monitor the blood level of anti-[MEDICAL CONDITION] medications because if the level is too high it can be toxic and if too low it may not be effective to prevent [MEDICAL CONDITION] activity. Further review of the medical record revealed that the resident had an order, with a start date of 8/17/15, for a PT/INR (a lab test requiring a blood draw) weekly on Monday and Thursdays. Based on this order, there were at least 4 opportunities for the [MEDICATION NAME] Acid level to have been drawn between 8/17/15 and 9/2/15. On 9/4/15 at 3:40 PM the nurse practitioner confirmed that the resident was taking [MEDICATION NAME] Acid for [MEDICAL CONDITION]. On 9/4/15 further review of the electronic health record revealed an order, dated 9/2/15 for a [MEDICATION NAME] Acid level to be drawn on 9/3/15. Results of this lab test revealed a [MEDICATION NAME] Acid level of 20.84 which is low, based on a reference range of 50 -100. Further review of the medical record revealed a new order for [MEDICATION NAME] Acid, dated 9/3/15, for 750 mg to be given two times a day. This new order represents a 500 mg per day increase. 5. On 9/3/15 at 11:30 AM Resident #53's medical record was reviewed. This review revealed a pharmacy review dated 8/4/15 which revealed a recommendation made to the attending physician that stated: Patient receives Calcium 500 mg pe[DEVICE]. Please consider changing Calcium to Calcium w/vitamin D 600/400 pe[DEVICE] QD for supplement. Further review of the pharmacy recommendation revealed the physicians response: Accept the recommendations above please implement as written. Review of the August 2015 and September 2015 physician's orders [REDACTED]. Further review of the physician orders [REDACTED].During an interview with the 2nd floor unit manager on 8/3/15, while reviewing the pharmacist recommendation, he reported that when the physician agrees with the recommendation and says implement, the staff should have written the order. He acknowledged that the order should have been written on 8/4/15 when the physician agreed with the recommendations and that the facility failed to follow the physician orders.

Based on observations; staff, resident and family interviews; and review of medical records, policies, and other documentation, it was determined that the Medical Director failed to coordinate medical care in the facility by not having effective systems in place for quality assessment performance improvement (QAPI) activities, for documentation and communication systems to report important events that could affect health and safety of residents, for adherence to policies regarding the use of elopement interventions, and for verbal order systems. These concerns were evident for 2 of 55 residents (#74 and #9) reviewed during survey and placed all residents at increased risk for serious harm and for similar rights violations. These concerns also contributed to findings of immediate jeopardy when two serious preventable adverse events were not found documented anywhere and were not identified and addressed through any QAPI activities. Resident #74 was sent to the hospital for psychiatric evaluation in error, and Resident #9 was placed on a WanderGuard and confined to a unit for wandering when there was no documentation of the need for such intervention. An immediate jeopardy was identified on August 28, 2015 at 2:00 PM. A plan to remove the immediacy was submitted to the survey team on August 28, 2015 and accepted at 7:40 PM. After removal of the immediacy, the deficient practice continued at the potential for more than minimal harm with a scope/severity of E level for the remaining residents. Cross reference: F155, F223, F272, F309 and F520. The findings included: 1. Resident #74 was sent out to a local acute care hospital for psychiatric evaluation on 7/21/15 after the unit manager obtained a verbal order. In interview on 8/28/15, the physician stated that he was ordering that staff send resident #9 and that there was no clinical justification to send resident #74. In interview on 8/28/15, the physician reported that when he signed off on the verbal orders he clicked all of the verbal orders with one click in the electronic system and so he did not actually check the orders. In addition to the adverse event where resident #74 was sent to the hospital, resident #9 was never sent. The 7/21/15 hospital emergency department record for resident #74 revealed that nursing home staff realized that resident #74 had been sent in error and called the hospital to request the resident be sent back. The hospital record also documented that staff reported to the hospital that the resident sent in error had the same last name as the resident that should have been sent. In interview with GNA #1 on 8/28/15, she reported that she spoke to the resident who reported being very upset about having been sent to the hospital, but she believed this was a problem from another shift so she never reported it to anyone. In interview with the physician on 8/28/15, he reported that he learned of the mix up and saw resident #9 two days later. The physician stated that by then resident #9 seemed stable enough that he/she no longer needed to go out for an urgent evaluation so he decided to just let it go. These two adverse events were not found documented anywhere as required under standards of practice and in regulatory requirements. The medical record for resident #74 was not updated to reflect the resident was called back after staff determined he/she had been sent in error. The medical record for resident #9 revealed no order, note or Any other indication that he/she should have been sent. The facility transfer log was not updated to reflect that resident #74 was sent to the hospital or that the resident returned with family after nursing home staff called the hospital. In interview with the Administrator on 8/28/15 she reported that no incident reports were filed for either adverse event. In interview with the lead QA consultant and the DON on 8/28/15, they both reported that they were not aware that resident #74 was sent in error and that resident #9 was never sent. Neither event was reported to the State Office out Health Care Quality as required as an unusual occurrence. In conference/interview with senior staff on 8/28/15, they reported an inaccurate belief that they were not required to report these events because there was no harm. With all of these documentation system and communication system failures, both the DON and the lead Quality Consultant reported that they did not even know these events had occurred prior to the survey. The facility QAPI program failed to identify either of these serious adverse events that occurred during the provision of care and failed to then take any actions whatsoever to identify potential causes of the events and failed to develop any actions to address the causes to protect other residents from suffering similar events in the future. 2. An alert and oriented resident (#9) was involuntarily secluded with multiple interventions intended to restrict her/his freedom of movement after she/he had repeatedly expressed the desire to leave the facility.Resident #9 was admitted to the facility on [DATE]. The admission MDS assessment (assessment reference date 7/18/15) and a quarterly MDS assessment (assessment reference date of 7/31/15) revealed that the resident was assessed with [REDACTED]. The BIMS is an assessment that assists staff in determining a resident's cognitive understanding. A BIMS score of 13-15 indicates that a resident is cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment.The admission MDS screening also corroborated (in section B at items B0700 and B0800) that Resident #9 usually was able to understand others and usually was able to make herself/himself understood.In review of the medical record on 8/27/15, no certifications were found documented in the record indicating that Resident #9 could not make his/her own decisions. In interview with the social worker on 9/4/15 at 10:59 AM, the social worker confirmed that there were no certifications demonstrating that Resident #9 was unable to make her/his own decisions. She added that Resident #9 was alert, oriented, and able to make his/her needs known. In the MDS Admission screening, coding in section E (Behavior) MDS item E0900 indicated that Resident #9 had been coded with signs and symptoms of wandering behavior. When completed late on 7/29/15, the Admission MDS screening triggered (identified the need for) the CAA (Care Area Assessment) regarding the coded behavioral concern. Under standards of practice, an objective elopement assessment should have been conducted prior to instituting elopement interventions that restricted Resident #9's freedom of choice and movement. Further, by facility policy, an objective assessment of elopement risk should have been conducted when Resident #9 was first admitted . When asked by the survey team on 8/28/15 for the facility policy on managing elopement risk, the Administrator provided a one page information sheet. Twice on 8/28/15, the Administrator stated that the document provided was the facility policy. The policy sheet (from a larger reference document) contained a header at the top of the page entitled, Phase 1: Assess (CONT) defined and described elopement. Guidance from the policy was limited but did reveal that there was an expectation that an elopement risk assessment would be conducted for all new admissions. In a statement with no defined exclusions, the policy sheet indicated that patients are evaluated upon admission for a history of, or risk factors for wandering and, or exit seeking. Despite this policy statement, in interview at approximately 12:30 PM on 8/28/15, the Director of Nursing stated that the facility actually did not conduct any elopement risk assessments for residents on admission. The medical record revealed that without any assessment of resident #9's elopement risk even though called for in facility policy, staff initiated multiple interventions that held resident #9 on a secure unit from which he/she could only leave with staff consent and assistance after the alert and oriented resident had repeatedly expressed his/her wish to leave the facility. On 7/13 resident #9 had repeatedly asked to leave but was instead placed on a WanderGuard system, was moved to a second floor unit that had an elevator that locked down when approached by someone on the WanderGuard system, and was subjected to 24/7 one-to-one staff supervision. Resident #9 was not allowed to leave the facility against his/her will and was instead involuntarily secluded with these multiple interventions from 7/13/15 through 8/1/15. The failure of the Medical Director to ensure that policies were in place, were effective, and were followed left resident #9 confined to the facility against his/her will for 19 days. These failures regarding Resident #74 being sent to the hospital for psychiatric evaluation in error, and Resident #9 being placed on a WanderGuard and being confined to a unit for wandering when there was no documentation of the need for such intervention, resulted in an immediate jeopardy being identified on August 28, 2015 at 2:00 PM. A plan to remove the immediacy was submitted to the survey team on August 28, 2015 and accepted at 7:40 PM.Steps taken by the facility to remove the immediacy included, but were not limited to: an audit of those residents with security bracelets to assess the compliance with the Wander Practice guidelines, education of staff on the alert bracelet and secured unit guidelines, an audit of those residents with like names to ensure those charts had alert stickers, audit in-service of staff on verbal orders and acute setting transfers, and a Quality Assurance monitoring plan.

Based on review of facility policies, medical records, and interview with facility staff, residents and families, it was determined that the facility: (1) Failed to have a system in place to assess, determine and follow the code status of residents when decisions made by the facility staff were inconsistent with wishes of the resident and/or the responsible party, thus putting the resident at risk for death by not performing CPR in the event of [MEDICAL CONDITION]; (2) Failed to have the current MOLST in the residents active medical record; (3) Failed to obtain certifications of incapacity to make an informed decision prior to discussing the orders for life sustaining treatment with the resident's health care agent, rather than the resident him/herself; (4) Failed to void a MOLST form ordering CPR when a new MOLST was completed which ordered No CPR leaving both inconsistent MOLST documents in the current medical record; (5) Failed to ensure that electronic orders for code status were consistent with MOLST order documentation in the medical record; and (6) Failed to update the resident's MOLST status to DNR when two certifications of Medical ineffectiveness were completed. These related concerns were evident for 10 of 25 residents reviewed for the choices care area during the Quality Indicator Survey (Residents #53, #20, #17, #67, #234, #171, #85, #155, #32, and #279). These failures resulted in an immediate jeopardy being identified related to incorrect code status and life sustaining treatment orders. The immediate jeopardy was called on [DATE] at 3:25 PM and the immediacy was removed on [DATE]. After removal of the immediacy, the deficient practice continued the potential for more than minimal harm with a scope/severity of E level for the remaining residents. The findings include: MOLST (Maryland Medical Orders for Life-Sustaining Treatment) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options. 1. On [DATE] at 11:30 AM Resident #53's medical record was reviewed. This review revealed a MOLST form dated [DATE] which revealed that the resident was a full code (meaning in the event of [MEDICAL CONDITION] CPR would be performed). On [DATE] a new MOLST form was completed by the Attending Physician indicating that the resident was a no CPR (meaning in the event of [MEDICAL CONDITION] the facility would not perform CPR). Further review of the medical record revealed Social Work (SW) notes dated [DATE] and [DATE] indicating that the MOLST was reviewed and the resident was a full code. During an interview with the SW on [DATE] at 11:45 AM, the SW was asked for any documentation in reference to the resident's code status changing on [DATE]. At that time, the SW revealed that the physician came in to see the resident on [DATE] so he may have had a discussion with the resident's responsible party.On [DATE] at 12:30 PM, the resident's responsible party was interviewed. The responsible party informed the surveyor that the the resident was a full code and the facility was fully aware of his/her wishes. On [DATE] at 12:45 PM the surveyor asked Staff #1 if the resident was found without a pulse, what she would do. After reviewing the MOLST, Staff #1 revealed she would not do CPR. The second floor unit manager was also questioned on the resident's code status. He revealed that as of that moment the resident was a DNR/DNI (Do Not Resuscitate / Do Not Intubate).During a phone interview on [DATE] at 1:00 PM, the attending physician stated, I don't understand why there is a 'no code' on the chart. He then asked the surveyor if the MOLST was signed by him or the hospital physician. The surveyor gave the license number from the MOLST and the physician confirmed that it was his number. The physician then stated, I don't know why there is a discrepancy, we have had many discussions, but I am not clear on that issue of code status. I usually have a clear discussion with the patient and the family so I don't know all the details on this issue and don't know why there is an issue; we will clearly have to modify. I'm sorry it's just not clear on my mind, it's clearly upsetting. From [DATE] until [DATE], Resident #53 had two contradictory orders in the medical record indicating both full code status and no code status. 2. On [DATE] at 12:30 PM Resident #20's medical record was reviewed. This review revealed a MOLST form dated [DATE] indicating the resident was a Full Code (meaning in the event of [MEDICAL CONDITION] CPR would be performed). However, review of Resident #20's thinned record revealed a newer/updated MOLST form written on [DATE] indicating the resident was changed to DNR/DNI (Do Not Resuscitate/Do Not Intubate; meaning in the event of [MEDICAL CONDITION], CPR would not be performed). However the older order was maintained in the medical record and the current order was removed when the chart was thinned (thinning a chart refers to removing older documentation that may not be necessary for tracking day to day care delivery). Review of the SW note dated [DATE] revealed that the SW met with the patient on this date. Code status was reviewed, patient requested to be a DNR/DNI, and physician was in house and made aware. The SW and physician met with the resident and reviewed the MOLST, the physician completed the MOLST form on this date reflecting the resident's wishes of a DNR/DNI status.During an interview with Resident #20 on [DATE] at 1:05 PM this surveyor asked if he/she was familiar with CPR and the resident reported kind of. The resident asked if that is when they keep you alive or try to. The resident then stated, Honey I am [AGE] years young I have lived a good life, and I don't want that. Now, if I was much younger then I would have to think about it.During an interview with the SW on [DATE] at 1:54 PM, she reported that she was not aware of the current MOLST to be a DNR. The SW acknowledged that the old MOLST should have been removed from the resident's chart and the current MOLST with DNR/DNI should have been kept in the resident's chart. From [DATE] until [DATE] an older expired order was maintained in the medical record for Resident #20 that was not voided and indicated the resident was still a full code. Staff believed this older order was the current and accurate order leaving Resident #20 at increased risk for harm in the event he/she suffered a cardiopulmonary event. 3. On [DATE] at 12:30 PM Resident #17's medical record was reviewed. This review revealed a SW note dated [DATE] which stated certification for end stage/medically ineffective flagged in chart for physician review, and a MOLST form flagged in chart to reflect full code status.Review of the physician progress notes [REDACTED]. Further review of the medical record revealed a Physician Certification of Medically Ineffective Treatment dated [DATE] which certified that CPR would be medically ineffective. However, review of the MOLST dated [DATE] revealed that the resident was still a full code, meaning CPR would be attempted including intubation. The documented MOLST orders did not reflect the current physician orders and no facility systems identified the inconsistency between the orders that placed Resident #17 at increased risk for harm. 4. On [DATE] at approximately 8:00 AM review of Resident #67's medical record revealed a [DATE] MOLST form, which documented that the orders were entered as a result of a discussion with and the informed consent of the patient's health care agent as named in the patient's advance directive. It also stated that CPR should be attempted if cardiac and/or [MEDICAL CONDITION] arrest occurred. Further review of the medical record failed to reveal any advance directives for this resident, nor were there any Physician Certifications of Incapacity to Make an Informed Decision forms found.A social services note dated [DATE], included the following: Rt (resident) reports no advance directives documents are in place at this time. There was no mention of the MOLST form or what the resident's wishes were in regard to life sustaining treatment found in the [DATE] social service note.Further review of the medical record revealed the following [DATE] social service note: MOLST reviewed - rt (resident) is full code. However, there was no indication as to whom the MOLST was reviewed with on [DATE]. On [DATE] at 10:54 AM the Social Worker confirmed that the resident is his/her own responsible party. The surveyor then reviewed the above information with the Social Worker, the Medical Director and the Administrator. On [DATE] at 2:01 PM surveyor reviewed with the Administrator that further review of the medical record failed to reveal any documentation that a discussion had occurred with the resident regarding code status and then at 2:55 PM this information was reviewed with the Regional Director.On [DATE] at 3:30 PM the facility provided a nurse practitioner note, dated [DATE] at 1:47 PM that included the following: .Also discussed MOLST form with patient today, patient states, I feel like I have lived my life, so I do not want anything drastic to try to save me or prolong my life, I have been blessed so far <and> Patient wants to be DNR/DNI .Further review of the medical record at 3:30 PM revealed a new MOLST, dated [DATE], documenting Resident #67's expressed desire after discussion and with his/her informed consent that No CPR, Option B Palliative and Supportive Care was ordered. This order included: If cardiac and/or [MEDICAL CONDITION] arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. From [DATE] Resident #67 was deemed and was ordered to be a full code based on the determination of someone not authorized to make that decision. When the resident was asked his/her own wishes on [DATE], the resident indicated that he/she in fact did not wish to be a full code in the event he/she suffered a cardiopulmonary arrest.5a) On [DATE] at 10:40 AM Review of Resident #234's medical record revealed a MOLST, dated [DATE], which documented that the orders were entered as a result of a discussion with and the informed consent of the patient's health care agent as named in the patient's advance directive.Further review revealed the resident's advance directives, dated [DATE], in which the resident wished for the surrogate (health care agent) to make decisions in the event that she/he were determined to be incapacitated and unable to provide consent for medical treatment. Review of the medical record failed to reveal any Physician Certification of Incapacity to Make an Informed Decision forms. At 10:56 AM this information was reviewed with the Social Worker, the Medical Director and the Administrator.On [DATE] at 11:45 AM staff provided a copy of the Physician Certification of Incapacity to Make an Informed Decision form, signed by two physicians, on [DATE] and [DATE]. Both of these dates were after the [DATE] MOLST was executed based on discussion with the health care agent. Further review of this form revealed that it was received by the facility on [DATE] at 11:21 AM.5b) Additionally, on [DATE] at 11:33 AM medical record review revealed a second, active, MOLST form for Resident #234. Review of this form revealed that it was completed on [DATE], was discussed with health care agent and included an order to attempt CPR. Contradicting this order, the other MOLST form in the open record was dated [DATE] and indicated Resident #234 was No CPR status. At 11:45 AM staff provided a copy of the [DATE] MOLST form that was voided on [DATE]. 6. Review of Resident #171's medical record on [DATE] at 7:30 AM revealed two social work notes, one dated [DATE] and one dated [DATE], regarding the resident's code status and indicating that the MOLST was flagged in the residents chart for the physician to review. In addition to the two paper MOLST forms in the record, the resident code status was also documented in the electronic order system. One of the paper MOLST forms, dated [DATE], documented that the resident was a full code. The second MOLST form, dated [DATE], documented that the resident was a No CPR, option A, do not intubate, other comprehensive efforts including limited ventilator support including [MEDICAL CONDITION] (continuous positive airway pressure) or [MEDICAL CONDITION] (bi-level positive airway pressure-- a non-invasive way to administer oxygen) could be used. Under standards of practice, as of the [DATE] date, the earlier MOLST orders were void and should have been noted as discontinued. The nurse practitioner's note from [DATE] documented a comprehensive monthly review of the resident, to include the resident being a DNR, but may intubate. This was inconsistent with the resident's wishes that had been documented in the MOLST from [DATE].Review of Resident #171's electronic medical record on [DATE] at 8:00 AM also revealed documentation that inaccurately indicated that the resident was still a full code. Interview with the facility quality assurance nurse at 8:15 AM on [DATE] revealed that there was an error and no one had changed the resident's 'bundle' order. Therefore, on the main screen when the residents profile was pulled up on the computer it showed that the resident's code status was 'Full Code.' After surveyor intervention, the administration completed a facility wide audit of documentation of resident code status and life sustaining interventions. On [DATE] at 8:10 AM, after the audit, LPN #3 was asked Resident #171's code status and she stated that she/he was made a DNR 'last night.' Review of the resident's physician orders revealed a new order for DNR/DNI as of [DATE]. However, even after this order change, on [DATE] at 8:15 AM the electronic medical record for Resident #171 remained inconsistent, still indicating that the resident was a full code.7. Review of Resident #85's medical record on [DATE] at 1:00 PM revealed a social work note dated [DATE]. The note stated that certifications of medical ineffectiveness were flagged in the resident chart for physician review at the request of the resident's guardian. A social work note on [DATE] stated that the certifications remained flagged in the residents chart for physician review. As of [DATE] the certification of medical ineffectiveness were still not reviewed or completed. The medical record revealed that Resident #85 was ordered to be Full Code. According to the social work notes, the resident's code status could not be changed from full code to DNR status as was requested by the resident's guardian on [DATE], until the certifications were completed by the physician. Despite the fact that the concerns had been documented about medical ineffectiveness and the fact that the guardian had requested the code status change, with the certifications not complete, Resident #85 remained Full Code for more than three months. Additionally, there were three copies of the same MOLST in three different sections of the resident's medical record, one of which was unsigned by a physician. Should there be a change in the residents' MOLST, it was unlikely that all of the MOLST documents would be corrected. 8. Review of Resident #155's medical record, on [DATE] at 10:22 AM revealed that a MOLST was completed on [DATE] stating that the resident's guardian had chosen for the resident to be a full code. Review of the residents medical record did not reveal any certifications of incapacity for the resident to make informed decisions regarding medical care. Therefore, without the certifications, the resident should have been making his/her own decisions regarding medical care.review of the resident's medical record revealed [REDACTED]. Therefore, the resident should still have been making his/her own decisions regarding issues surrounding medical care. A second certification of incapacity to make medical decisions was completed on [DATE] at 1:00 PM, after the findings were brought to the facility's attention by the surveyors on [DATE]. 9. Medical record review on [DATE] at 7:05 AM revealed that Resident #32 had 2 MOLSTs on his/her active medical record, neither were voided, and they were dated [DATE] and [DATE]. Resident #32's medical attending reviewed the resident's MOLST on [DATE] and stated the (patient) agreed with the status of the document. However, closer review of the front and back of the [DATE] MOLST by the surveyors on [DATE] at 7:05 AM, revealed contradictory information. Review of the [DATE] MOLST revealed that the resident did not want intubation or artificial ventilation, CPR only. This was not documented on the front of the MOLST; only on the back, which if copied is not required to be sent with the resident to the hospital. There was also no clarification completed or reviewed with the resident regarding wanting CPR but no intubation. Once CPR is initiated, intubation would be the next step if needed. Additionally, on the front of the MOLST, CPR was selected which includes artificial ventilation.This was brought to the attention of the facility RDO (regional director of operations) at 9:00 AM on [DATE], who stated that intubation, would not occur in the facility. This surveyor stated that the MOLST goes with the resident to the hospital and the resident would be intubated in the ambulance or at the hospital if needed.The MOLST was reviewed with the facility Social Worker on [DATE] at 3:48 PM and a new MOLST was completed on [DATE] with the resident, the social worker and the facility nurse practitioner, who according to the social worker went over the MOLST in detail and step by step with the resident. The resident chose to have intubation for a limited amount of time, which was then documented appropriately on the MOLST form.Review of the facility policy on Limited Treatment Practices on [DATE] revealed that according to section V. procedures for withholding life sustaining treatment, subcategory A. The physician must 1.a document the patient's or appropriate legal representative's consent in the medical record or MOLST form; g. when the order to withhold life sustaining procedures is issued, the attending physician must document every aspect of these procedures, including writing the order in the chart, recording the determination that the patient is incapable of making an informed decision, providing reasons for the order, describing the patient's medical condition and prognosis, and indicating the date and nature of the discussion with the patient and agent or surrogate; and 2. The nursing staff must: b document every aspect of these procedures, including but not limited to, physician orders, progress notes, nurses' notes, and social services notes. 10. Review of Resident #279's clinical record on [DATE] at 7:01 AM revealed that the resident decided that his/her code status was to be Do Not Resuscitate (DNR) on [DATE]. The resident was capable of making his/her own decisions. The MOLST form was not signed by the physician until [DATE] and the primary physician did not write a note on this change until [DATE]. Nursing staff did not document in the progress notes of the clinical record that the resident was DNR until [DATE] at 1:33 AM. Due to these serious concerns regarding the appropriate code status for residents in this facility, on [DATE] at 3:25 PM an immediate jeopardy was called by the Office of Health Care Quality related to the facility's failure to have a system in place to assess and ensure the desired code status of the resident or their responsible party was correctly reflected in the medical records. A plan to remove immediacy was submitted to and accepted by the survey team on [DATE] at 8:58 PM. The audit tools proved ineffective and the facility then completed an updated plan to remove immediacy and it was accepted by the survey team on [DATE] at 8:20 PM. The facility was notified that although the updated plan was accepted, validation of the plan would take place before the immediacy was removed. The facility plan indicated a completion time of 7:00 AM on [DATE]. On [DATE], the survey team found that the implementation of the plan was underway but not complete. On [DATE] another plan revision was submitted to the surveyors and was accepted at 2:00 PM. Surveyors validated that the final plan was fully implemented and immediacy was removed at 8:45 PM on [DATE]. Steps taken by the facility to remove the immediacy included but were not limited to: a full 100% audit of resident records to ascertain the desired code status and ensure that this matched with the most current physicians order; an audit of those residents transferred and readmitted to the facility within the past six months; corrections to MOLST that were found to not reflect the resident or responsible parties current desires; and reeducation of Social Services staff, licensed nurses, the Medical Director and attending physicians on the MOLST process.

Based on interviews with staff, residents and family, and review of medical records, policies, procedures and other (hospital) documentation, it was determined the facility failed 1. to ensure that MDS comprehensive assessments were completed as required to ensure individualized needs of residents were understood and addressed. This was evident when an alert and oriented Resident (#9) with capacity to make his/her own decisions was involuntarily secluded with interventions designed and implemented to restrict his/her freedom of movement, based on an unsupported rationale that the facility was keeping the resident safe. The medical record revealed that Resident #9 was able to make his/her own decisions and should have been allowed to leave the facility but without any care area assessment related to behavioral/elopement risk, the resident was not allowed to leave and was instead involuntarily secluded to a restricted unit for 19 days. The facility also failed to accurately assess a resident's PASRR (pre admission screening and resident review) on the Minimum Data Set (MDS) (#249). These concerns were evident for 2 of 55 residents sampled during this survey.The failure of the facility to conduct MDS comprehensive assessments for Resident #9, which resulted him/her being involuntarily secluded to a second floor unit, resulted in the determination of an immediate jeopardy situation being identified on August 28, 2015 at 2:00 PM. The Office of Health Care Quality accepted the facility plan to remove immediacy at 7:40 PM on August 28, 2015 while on site. After removal of the immediacy, the deficient practice continued the potential for more than minimal harm with a scope/severity of D level for the remaining residents. The findings include: The Minimum Data Set (MDS) is part of the broader Resident Assessment Instrument (RAI). The RAI/MDS process is a multi-disciplinary team process and requires communication amongst the team members to be effective. An RAI assessment must be completed by day 14 of a new admission and then updated periodically. The RAI includes the MDS screening, the Care Area Assessment (CAA), and Utilization Guidelines. 1. Resident #9 was admitted to the facility on [DATE]. Review of Resident #9's medical record on 8/27/15 revealed an admission MDS assessment (assessment reference date 7/18/15) and a quarterly MDS assessment (assessment reference date of 7/31/15) documenting that the resident was assessed with [REDACTED]. A BIMS score of 13-15 indicates that a resident is cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment.The Admission MDS screening (assessment window of 7/12/15 - 7/18/15) also corroborated (in section B at items B0700 and B0800) that Resident #9 was usually able to understand others and was usually able to make herself/himself understood. The MDS Admission Assessment screening with an assessment reference date of 7/18/15 also identified that Resident #9 was at particular risk for behavioral concerns and that these concerns were related to wandering. Coding in MDS section E (Behavior) Item E0900 indicated the resident had been coded for wandering and the MDS screening therefore triggered the Care Area for behavioral symptoms. Under the mandated RAI/MDS care process, the facility was required therefore to conduct a comprehensive assessment of this care area to ensure that care plans developed would meet the individualized needs of Resident #9. However, the MDS Admission screening was not completed timely. The RAI process deadline was 7/24/15, but the MDS assessment revealed that the screening was not completed until 7/29/15.Although required, no objective elopement risk assessment was found in the medical record that might have constituted a comprehensive CAA (Care Area Assessment) to support initiating an elopement risk care plan. The MDS CAA worksheet only stated that the resident, wandered the hallways on his/her first night as <she/he> was not used to the new environment. This one observation was not an objective and comprehensive assessment of Resident #9's needs related to the identified behavioral concern. Also, the one statement in the CAA worksheet was late when signed off on 7/29/15. Without any documented assessment, a care plan for elopement risk was generated for Resident #9 on 7/14/15. However, the care plan did not reflect the resident's preferences, strengths and needs. With no assessment, the plan was generated three days after admission and one day after the resident had been moved to the restrictive second floor unit against his/her will. Review of the care plan revealed that the plan also was not updated after the MDS screening window closed on 7/18/15. The regulations require that the care plan reflect the resident preferences, strengths and needs after conducting the CAA; but in this case, the care area assessment was never conducted. The care plan noted that the resident wanted to go home and was an elopement risk even though no objective documentation anywhere in the record supported any significant level of actual elopement risk. The interventions documented in the care plan included the following: calmly redirect the resident to an appropriate area; check for presence and function of alert bracelet every shift; educate family and visitors to advise staff when leaving patient following visit; encourage socialization with others and provide recreational programming; and last, remove items that may trigger attempt to leave facility (i.e. boots, coats .). However when this care plan was generated on 7/14/15, front line staff members were already employing the additional unplanned interventions of (1) placing the resident on a restricted unit behind a locking elevator; and, (2) adding 24/7 one to one supervision, neither of which were reflected in the care plan. Review of the medical record revealed that with no supporting evidence documented, two days after the 7/11/15 admission Resident #9 was deemed an elopement risk on 7/13/15. On or by this same date, three related interventions had been implemented. These three interventions were (1) placing a WanderGuard bracelet on the resident's ankle; (2) moving the resident to the second floor unit behind a locking elevator; and (3) placing the resident on 24/7 one to one staff supervision. A nursing progress note dated 7/13/15 at 1:12 PM documented that the resident, states he/she will go home today and was seen ambulating around the unit from time to time. A progress note dated 7/13/15 at 6:22 PM indicated that the resident would be transferred to the second floor. Interviews with senior staff on 8/28/15 revealed that the facility second floor elevator locked down when anyone wearing the WanderGuard bracelet approached so that no-one with a WanderGuard could leave on their own. Interview with the Unit Manager and later with the Administrator (both on 8/28/15) revealed that the intent and the effect of these combined interventions was that Resident #9 could not leave the second floor unit without direct staff assistance and supervision. On 8/28/15 during an interview with the Administrator, she described Resident #9 with a high risk for elopement and indicated that the restrictions were necessary to keep the resident safe. She stated Resident #9 had packed his/her bags and stood at the door wanting to leave the building and she indicated that Resident #9 had repeatedly stated his/her desire to leave the facility and go home. During an interview with the Unit Manager on 8/27/15 at 8:20 AM, he/she also stated that the second floor was more secure for individuals at risk for elopement. Review of the medical record revealed that there were no completed certifications supporting the conclusion that Resident #9 could not make his/her own decisions. In interview with the social worker on 9/4/15 at 10:59 AM, the social worker confirmed that there were no certifications and added that Resident #9 was alert, oriented, and able to make his/her needs known. Review of the medical record on 8/27/15, also revealed that no documented resident behaviors supported the combined interventions of the WanderGuard, the second floor placement, and 24/7 one to one supervision. No clinical notes were found describing any behaviors that might have supported consideration of such an intervention. By policy, an objective assessment of elopement risk should have been conducted when resident #9 was first admitted . When asked by the survey team on 8/28/15 for the facility policy on managing elopement risk, the Administrator provided a one page information sheet. Twice on 8/28/15, the Administrator stated that the document provided was the facility policy. The policy sheet (from a larger reference document) contained a header at the top of the page entitled, Phase 1: Assess (CONT). Although guidance from the elopement risk policy was quite limited, it did reveal that there was an expectation that an elopement risk assessment would be conducted for all residents at the time of admission. In a statement with no defined exclusions, the policy sheet indicated that, patients are evaluated upon admission for a history of, or risk factors for wandering and, or exit seeking. Despite this policy statement, in interview at approximately 12:30 PM on 8/28/15, the Director of Nursing (DON) stated that the facility actually does not conduct any elopement risk assessments for residents on admission. Also of note, in interview with the Administrator, DON and Quality Assurance (QA) Consultant on 8/28/15, both the DON and Administrator indicated that by policy, staff providing one to one supervision with a resident did not document resident behaviors anywhere. These staff only report behavioral concerns to the assigned nurse verbally. Thus, even if Resident #9 had been deemed unable to make her/his own decisions, no specific behaviors that might have supported using the combined interventions were found documented in the medical record. These multiple failures in following the mandated RAI/MDS process resulted in staff implementing entirely unsupported restrictions against an alert and oriented resident after she/he repeatedly expressed a desire to discharge out of the facility. Instead of honoring the resident's right to leave, the facility implemented use of an electronic WanderGuard system, moved the resident to a restricted unit behind a locking elevator and subjected the resident to 24/7 supervision of facility staff to ensure that the resident could not leave. With no documented assessment, restricting the resident's freedom of movement with the combined interventions constituted involuntary seclusion of the alert and oriented resident who could not leave the second floor unit without staff consent and could not leave the building at all. Of note, this same concern with the facility's failure to complete the required comprehensive CAAs was cited during a complaint survey conducted in June 2015 and a plan to correct this problem was submitted to the Office of Health Care Quality. On August 28, 2015 an Immediate Jeopardy was called at 2:00 PM related to a WanderGuard bracelet being placed on Resident #9 and the resident being confined to a unit for alleged wandering behaviors, when there was no documentation of the need for such intervention. The Office of Health Care Quality accepted the facility plan to remove immediacy at 7:40 PM on August 28, 2015 while on site. Steps taken by the facility to remove the immediacy included, but were not limited to: an audit of those residents with security bracelets to assess the compliance with the Wander Practice guidelines, education of staff on the alert bracelet and secured unit guidelines, and Quality Assurance monitoring plan. 2. Review of Resident #249's medical record on 9/2/15 at 9:30 AM revealed [DIAGNOSES REDACTED]. Continued review with the second floor unit manager revealed that the resident was identified by DDA (Developmental Disabilities Administration) as having a positive PASRR (Pre-Admission Screening and Resident Review. The PASRR is a federally mandated screening process designed to ensure that individuals are not admitted to or retained in nursing facilities when there are superior alternatives. Review of Section A1500 of the residents 6/18/15 admission MDS, revealed 'no' for 'is this resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability. Review of the resident's PASRR and [DIAGNOSES REDACTED]. She also stated that she was familiar with the resident and it was an error.

Based on review of medical record and staff interviews, it was determined that the facility nursing staff failed to provide and maintain adequate supervision and assistance resulting in the resident falling. This is evident for 1 out of 40 residents reviewed in the stage 2 sample. This occurred in the review of a facility reported incident MD 577. The findings include: Resident # 61 was readmitted to the facility in February 2013 with [DIAGNOSES REDACTED]. Review of the resident's medical record revealed that the resident was completely dependent on the facility staff for all ADLs (activities of daily living), and that the resident was completely immobile (Does not make even slight changes in body or extremity position without assistance). Further review of the resident's medical record revealed a physician's orders [REDACTED]. Review of the facility investigation revealed that, on 5/8/2013, at approximately 8:00 p.m. the assigned registered nurse and GNA (geriatric nursing assistant) were providing wound care to the resident in bed while the bed was at working height for the nurse. The resident was laying on the right side because the wound was located on the backside. While the nurse was applying a new dressing, the GNA supported the resident on the other side. Resident began defecating (having a bowel movement) as the wound was exposed, GNA turned away from bedside to grab wipes for cleaning. Without warning, resident's body started slipping and she rolled out of bed onto the floor mat. Her head hit the floor causing a laceration (a tear or opening in the skin caused by an injury). On 7/3/2013 during interview with the nurse (staff # 7) he stated, " During a dressing change, the GNA was supporting the resident's weight with her body, the resident had a bowel movement and the GNA stepped away to get something to clean up the resident, and without the support the resident fell . " During the interview with the nurse, he stated " better communication could have prevented the fall", if the GNA would have alerted me that she was stepping away, I could have provided support for the resident, thus preventing the resident from falling. On 7/3/2013, during an interview with GNA (staff # 6) she stated that, while the nurse was doing the dressing change, she was holding the resident by the shoulder and hip, the resident started stooling (having a bowel movement) and she walked away to get wipes and diaper, and before she could get out of the room, she fell . During the interview with the GNA she stated " better communication with the nurse could have prevented the fall " . Further review of medical record revealed that the resident was transported to the emergency room where it was revealed that the resident sustained [REDACTED].