Every finding on record at White Oak Rehabilitation and Nursing Center

Based on observations, staff interviews and record review it was determined that the facility failed to maintain a safe, comfortable homelike environment for Residents. This finding was found to be evident in review of the physical environment of the facility during the annual recertification survey.The findings include:During tour of the [NAME] Wing nursing unit at 7:28 AM on 6/15/2026 there were several Resident rooms that were observed not to be in good repair. The Resident rooms included:room [ROOM NUMBER] - room door marred down the side, wood splintered at top of door in left corner; missing handle to top drawer of dresserroom [ROOM NUMBER] - room door marred down the side, wood splintered at handleroom [ROOM NUMBER] - handle broken on bedside dresserroom [ROOM NUMBER] - room door marred, wood splintered at the top of door in left corner and around handleroom [ROOM NUMBER] - bathroom door marred, wood splinteredroom [ROOM NUMBER] - hole in closet door; room door marred, wood splintered around handle, overbed table marred with worn edges; missing handle to top drawer of dresserroom [ROOM NUMBER] - room door marred, wood chipped/splintered at handleroom [ROOM NUMBER] - bathroom door marred, large hole in bathroom doorroom [ROOM NUMBER] - bathroom door marred, bathroom door handle crackedIn an interview with the Maintenance Director at 7:50 AM on 6/22/2026 the surveyor reviewed a few of these areas in the Resident rooms that needed repair. In addition, the Maintenance Director and the surveyor toured the nursing unit and observed several of these Resident rooms that needed repair. The surveyor asked the Maintenance Director what system the facility utilized for notification of work order repairs. Maintenance Director stated that he received an email from staff for a work order repair and shared with the surveyor an example of an email that was received from staff for a work order repair.Additionally, the surveyor interviewed the Registered Nurse (RN) Unit Manager #21 and asked what system the facility utilized for work order repairs. RN #21 showed the surveyor the system/computer platform used by the nursing staff for entering work order repairs that triggered an email for Maintenance department. Licensed Nursing Home Administrator (LNHA) was notified of the concern with the physical environment of the facility at the time of survey exit. No additional information was provided by the facility at the time of exit.

Based on staff and Resident interviews, and surveyor record reviews it was determined that the facility failed to follow the care plan process which included invitation to care plan meetings, documentation of care plan meetings, and attendance at care plan meetings. This finding was found to be evident in 4 (Resident #6, #9, #52, and #108) out of 34 Residents reviewed for care plans during the annual survey. The findings include: 1) On 06/15/2026 at 10:00 AM, an interview with Resident #6's family member revealed the resident had not had a care plan meeting since earlier in the year. On 06/16/2026 at 11:11 AM, an interview with the Director of Social Services (Staff #3) revealed that care plan meetings were completed quarterly. She said that they reach out to the resident and/or resident representative when a care plan meeting was due and based on their availability, the facility would schedule one. At the same time, further interview with Staff #3 revealed that they did not document when they spoke with the resident and/or resident representative to invite them nor when they sent out a written invite. The surveyor requested the last care plan meeting for Resident #6 along with the invite and meeting notes On 06/17/2026 at 7:42 AM, Staff #3 provided the surveyor with a document that indicated that last care plan meeting for Resident #6 was 1/21/2026 and failed to show indication of when the invitation was provided to the resident and/or representative. Staff #3 indicated she had no further documentation to provide. The surveyor reviewed the concern. 2) On 06/15/2026 at 12:50 PM, an interview with Resident #9's family member revealed they had not been aware of a care plan meeting for the resident for a while. On 06/17/2026 at 7:43 AM, the Director of Social Services (Staff #3) provided the surveyor with the last care plan meeting for Resident #9 which was 11/19/2024. The surveyor reviewed the concern. On 06/16/26 at 2:25 PM the surveyor reviewed Resident #52's clinical record. The review revealed that Resident #52's Annual MDS assessment was completed on 01/08/26. There was no evidence in the clinical record to indicate that a care plan meeting was held with the Resident/Resident Representative and the Interdisciplinary Team within 7 days or around the time of the annual MDS assessment. On 06/17/26 at 9:30 AM in an interview, the Director of Social Services confirmed the surveyor's findings and stated that she had reviewed Resident #52's clinical records and could not find documentation for an interdisciplinary care plan meeting held around 01/08/26. 3) On 6/15/2026 at 12:16 PM in an interview with Resident #108, the Resident stated that he/she was not aware of a care plan meeting. In an interview with the Director of Social Services (SSD) at 11:15 AM on 6/16/2026 the surveyor asked what the expectation was for care planning process at the facility. SSD indicated that invitations for care plan meetings were conducted by phone through contact with the Resident's responsible parties (RP) and that the Residents in the facility were notified, and that the care conference invitations were left in the Resident rooms. SSD further stated that the care plan meetings were held within 72 hours of admission, quarterly and on discharge. Record review of Resident #108's medical record on 6/16/2026 at 12:58 PM revealed that Resident had care plan meetings on 7/24/2025, 9/5/2025, 2/20/2026, and 3/26/2026. There was no evidence in the medical record that a care plan meeting occurred for the months of December 2025 and June of 2026. The Minimum Data Set (MDS) assessment is a federally mandated clinical assessment tool used in all Medicare and Medicaid-certified nursing homes. MDS assessment evaluates a Resident's physical, psychological, and psychosocial functioning to determine care needs and calculate Medicare payment classifications. MDS assessment schedule mandates when nursing facilities must evaluate and document a Resident's health status. The MDS assessment schedule includes admission, quarterly, annual, and significant change in status of a Resident. Care plans in long term care are a personalized document outlining the specific medical, physical, and daily living needs of a Resident in a facility. It establishes concrete goals, required therapies, dietary instructions, and safety precautions to ensure consistent, high-quality support. Care plans are formally reviewed annually and updated every 3 months or whenever there is a significant change in the Resident's physical or mental health. The care plan is completed 7 days after the MDS assessment. In an interview with the Director of Nursing (DON) at 1:45 PM on 6/16/2026 the surveyor informed the DON that there was not a care plan meeting, care plan progress note, care plan attendance sheet and care plan invitation for December 2025 and June 2026 for Resident #108. The surveyor conveyed that the Quarterly MDS assessment was completed 11/25/2025 and the Annual MDS assessment was completed 5/27/2026 and the care plan meeting was to be completed 7 days after the MDS assessments. DON acknowledged the surveyor and stated that she would follow up with social services. The surveyor was provided with the following documents for Resident #108 which included multidisciplinary care conferences, care conference invitations, and care plan reports (attendance sheets) for 9/5/2025, 2/20/2026, and 3/26/2026. There was no documentation provided for December 2025 and June 2026 care plan meetings for Resident #108. In an interview with the SSD at 7:30 AM on 6/17/2026, the surveyor asked about the care plan meetings and invitations for December 2025 and June 2026 for Resident #108 as there was no documentation in the medical record and the facility did not provide the surveyor with documentation for these two (2) care plan meetings. Additionally, there was a Quarterly MDS assessment completed on 11/25/2025 and an Annual MDS assessment completed on 5/27/2026, and the care plan meetings should have been completed within 7 days after these MDS assessments. SSD acknowledged the surveyor and stated that she would follow up. In a follow up interview at 9:15 AM on 6/17/2026 with the SSD, she indicated that a care plan meeting was scheduled for June 24, 2026, for Resident #108, but there was not a care plan meeting in December of 2025. At the time of survey exit no additional information was provided by the facility.

Based on observation and interview, it was determined that the facility failed to ensure food was stored in accordance with professional standards of practice for food service safety. This was evident during the initial observation of the kitchen upon facility entry.The findings include:On 06/15/2026 at 7:12 AM, an observation of the drink refrigerator revealed approximately 13 individually wrapped sandwiches which were peanut butter and jelly as well as lunch meat sandwiches. The sandwiches were not labeled nor dated. The sandwiches felt stale to touch as the bread felt hard through the sandwich wrapper.On 06/15/2026 at 7:14 AM, Dietary Manager (Staff #8) introduced himself to the surveyor and was present for the remainder of the kitchen observation. The surveyor reviewed the concern regarding the sandwiches from the drink refrigerator. On 06/15/2026 at 7:16 AM, an initial observation of the walk-in food refrigerator revealed halal chicken, hotdogs, yellow mustard, mayonnaise, a pan of fish, approximately 5 lunch meat sandwiches in a steel pan which were not properly sealed closed, cinnamon coated canned apple slices in a bowl, unsalted butter block, and 3 stacks of yellow cheese which were opened, not labeled, and not dated. On 06/15/2026 7:18 AM, an initial observation of dry storage room revealed a bag of multi colored pasta, a container of beef flavored base, and the following seasonings: lemon pepper, thyme leaves, and parsley leaves which were opened, not dated, and not labeled. On 06/15/2026 at 7:19 AM, an interview with the Dietary Manager (Staff #8) revealed that the expectation of staff when an item was opened for the first time or an item was prepared and placed back into the dry storage room or the refrigerator, that it was labeled with the item name, date it was opened, and a use by date. The surveyor reviewed the concern.

Based on observations, staff interviews and record review it was determined that the facility failed to maintain a safe, functional, sanitary, comfortable environment for Residents, staff and visitors. This was found to be evident in review of the physical environment of the facility, kitchen and the laundry room during the annual recertification survey. The findings include: 1) On 06/15/2026 at 7:46 AM, the initial observation of the facility kitchen upon initial facility entry revealed a visibly unsanitary environment around the kitchen dishwasher. At the same time, further observation of the facility kitchen revealed visibly unsanitary walls behind one of the kitchen food preparation tables across from the oven. On 06/15/2026 at 7:23 AM, an interview with Dietary Manager (Staff #8) revealed his expectation was for the dishwasher and food preparation areas to be visibly clean. The surveyor reviewed the concern. 2a) On 06/18/2026 at 7:38 AM, during an observation of the facility on the main floor revealed cracked siding pieces on lower walls, cracked corner protectors, and peeled off wall trim throughout halls outside of resident rooms. The following were where these concerns were identified: Outside of room [ROOM NUMBER], the siding piece on the lower wall was crackedOutside of room [ROOM NUMBER], the corner of the siding piece on the lower wall was crackedOutside of room [ROOM NUMBER], the corner protector on the doorway was crackedOutside of room [ROOM NUMBER], the corner protector on the doorway was crackedOutside of room [ROOM NUMBER], the corner protector on the doorway was crackedOutside of the room labeled as central bath, the lower wall trim was detached from the wall/peeling off approximately 8 inches. 2b) On 06/18/2026 at 7:46 AM, an observation of the facility elevator revealed approximately 5 noticeable areas where the light brown colored wall trimming was chipped. On 06/22/2026 at approximately 2:45 PM, the concerns were reviewed with the Nursing Home Administrator during the survey exit conference. 3) On 6/16/2026 at 7:31 AM observed in the corridor were three (3) stained ceiling tiles outside of the business office. Further down the corridor outside of the dietary department was one (1) stained ceiling tile. At 7:10 AM on 6/22/2026 the surveyor observed the laundry rooms with the Environmental Services Director (EVS) in attendance. Observed in the washer room over the two (2) commercial washers was a ceiling light cover that was missing and the bulb/light was out, not operable and it was dark towards the back of the room. Additionally, there was a plate guard on the wall that was cracked where the door handle hit the wall when opening the door. Also, the door and wall were loose to the chemical storage room. Further observation of the laundry room where the lockers were located was a large plastic bottle of a purple-colored substance sitting on the floor which the EVS Director stated was Fabuloso, a highly concentrated, multi-surface liquid cleaner. This area was not secured/locked and there were Resident rooms in the hall adjacent to the laundry room. In an interview with the EVS Director on 6/22/2026 following the observation of the laundry rooms, the surveyor asked if the Maintenance department was aware of the ceiling light, plate guard and door/wall. EVS Director stated that she would let Maintenance know. During an interview with the Maintenance Director at 7:50 AM on 6/22/2026 he was notified of the stained ceiling tiles in the corridor and the ceiling light in the laundry room. The surveyor asked what system was used in the facility for notification of repairs that were needed. Maintenance Director stated that he received an email when a repair was needed and reviewed with the surveyor an example of an email that he received in the facility. No additional information was provided by the facility at the time of survey exit.

Based on medical record review and staff interviews, the facility staff failed to obtain consent from the responsible party for a new psychotropic medication (Mirtazapine) ordered for Resident #131 who lacks decision-making capacity. This was evident for 1 of 5 residents reviewed for psychotropic medication during the annual survey.The findings include: On 06/18/2026 at 9:33 AM Resident #131's medical records were reviewed. The Psychiatry Progress Note stated the reason for the visit was increased depressive symptoms. Staff # 36, Nurse Practitioner (NP) gave a new order for Mirtazapine 15mg daily for depression on 1/7/2026. Further review of Resident #131's record revealed his Brief Mental Status (BIMS) was 3 indicating they lack capacity to give consent for the new medication Mirtazapine.On 06/18/2026 at 12:16 PM the Director of Nursing (DON) was interviewed and asked how long Resident #131 had been taking Mirtazapine and they stated for five months.On 06/18/2026 at 2:58 PM, the Nursing Home Administrator (NHA) was interviewed to request documentation confirming that the responsible party provided consent for the Mirtazapine order dated 1/7/2026. Following an investigation, the NHA confirmed that the informed consent assessment was not completed and acknowledged the failure to obtain the necessary consent for the psychotropic medication was an issue.

Based on record review and interviews, it was determined that the facility staff failed to ensure that a written bed hold notice was provided to the resident's representative. This deficient practice was evident for 1 (Resident #84) of 4 residents reviewed for discharge process during the annual survey.The findings include:On 06/18/2026 at 10:16 AM, a review of Resident #84's medical records revealed the resident was transferred to the hospital on [DATE]. Further review of the medical record failed to show documented evidence the resident's representative received the written bed hold notice following the hospital transfer.The surveyor informed the Director of Nursing (DON) that the resident records lacked evidence indicating the written bed hold notice had been provided to the resident's representative. The DON stated she would review the record and follow up with the surveyor.On 06/18/2026 at 12:44 PM, the DON provided a copy of an envelope addressed to the resident rather than the resident's representative. The envelope displayed a postage stamp date of 03/16/2026.The surveyor informed the DON that the date on the envelope was eight days prior to the resident's hospital transfer and inquired why the letter was addressed to the resident instead of the resident's representative. The DON stated the medical records staff had pre stamped mailing envelopes, and the facility had no documented evidence showing that the resident's representative had been provided with the written bed hold notice.

Based on staff interviews and surveyor record reviews it was determined that the facility staff failed to code Minimum Data Set (MDS) assessments accurately for a Resident. This finding was found to be evident in 1 (Resident #12) out of 7 Residents reviewed for use and indication of high-risk medications.The findings include:Comprehensive Care Plan is an individualized document maintained by an interdisciplinary healthcare team that outlines a Resident's medical, emotional, and daily living needs. It serves as a centralized roadmap to coordinate care, track progress, and ensure continuity across multiple providers. The comprehensive care plan includes medical and clinical summary (diagnoses and history, medications and supplements, and preventative care), goals and action plans including interventions and evaluations, activities of daily living and psychosocial needs, and risk and crisis management (risk assessments and emergency protocols).The surveyor conducted a record review of Resident #12's medical record on 6/17/2026 at 3:25 PM. Record review revealed that Resident #12 had physician orders for routine Insulin injections and sliding scale Insulin injections before meals and at bedtime based on blood sugar results. Additionally, Resident #12 had a comprehensive care plan created on 6/5/2024 for diagnosis of diabetes mellitus with insulin use.Medication Administration Record (MAR) is an official legal document used by healthcare professionals and care givers to track all drugs administered to a Resident. It ensures patient safety by logging exactly who received the medication, what was given, the dosage, the time, the route of administration, and the initials or the full signature of the healthcare provider who administered or verified each dose. The MAR is crucial for error prevention, accountability, and legal protection.Further review of Resident #12's medical record, specifically the medication administration records (MAR) on 6/17/2026 revealed that Resident was administered routine insulin injections and sliding scale insulin injections before meals and at bedtime based on blood sugar results.Minimum Data Set (MDS) assessment is a federally mandated clinical assessment tool used in all Medicare and Medicaid-certified nursing homes. MDS assessment evaluates a Resident's physical, psychological, and psychosocial functioning to determine care needs and calculate Medicare payment classifications. MDS assessments are completed on admission, quarterly, annually, discharge, and significant change in status of a Resident. The MDS assessment is completed by the clinical interdisciplinary team and coordinated by a Registered Nurse (RN) MDS Coordinator.The surveyor reviewed the MDS assessments for Resident #12 on 6/18/2026 at 7:15 AM. Review of the 3/5/2026 Discharge MDS assessment revealed that Section N0415 High-Risk Drug Classes: Use and Indication was not coded for Hypoglycemic (including insulin). Additionally, review of the 6/4/2026 Quarterly MDS assessment revealed that Section N0415 High-Risk Drug Class: Use and Indication was not coded for Hypoglycemic (including insulin).In an interview at 8:40 AM on 6/18/2026 with the Director of Nursing (DON) the surveyor conveyed the inaccurate coding on the 3/5/2026 Discharge MDS and 6/4/2026 Quarterly MDS assessments for hypoglycemic drug classes. DON reviewed the MDS assessments and acknowledged the inaccurate coding for hypoglycemic drug usage and stated that Resident #12 received insulin routinely and that she would review with the Regional MDS Director.At 9:50 AM on 6/18/2026 in a follow-up interview with DON, she stated that she reviewed the MDS assessments with the Regional MDS Director and confirmed that the coding on the MDS assessments was inaccurate as the Resident received insulin, and hypoglycemic medication usage should have been coded on the Discharge and Quarterly MDS assessments. DON indicated that they were completing a modification to the MDS assessments which would be coded that Resident received hypoglycemic medication (insulin).Follow up review of the medical record on 6/22/2026 at 8:43 AM revealed that a modification was completed to the 3/5/2026 Discharge MDS assessment Section N0415 which was now coded for hypoglycemic medication. There was not a modification completed for the 6/4/2026 Quarterly MDS assessment Section N0415. The surveyor conveyed to the DON at 1:00 PM on 6/22/2026 that there was not a modification completed for the 6/4/2026 Quarterly MDS assessment. DON stated that she would follow up with MDS Coordinator as there needed to be a modification completed.Prior to survey exit on 6/22/2026, DON provided the surveyor with a copy of the 3/5/2026 Discharge MDS and the 6/4/2026 Quarterly MDS assessments with the correction to Section N0415 High-Risk Drug Classes which was now coded for hypoglycemic (insulin) medication usage.

Based on an interview with facility staff and a review of resident medical records, it was determined that facility staff failed to follow professional standards of nursing practice when they did not schedule a follow-up appointment in a timely manner. This was evident for 1 (Resident #15) of 4 residents who were investigated during the annual survey.The findings include:On 06/17/2026 at 9:52 AM, a review of Resident #15's medical records revealed a progress note dated 6/3/2026 from Staff #37, a Nurse Practitioner (NP). The note indicated that Resident #15 was 75 days post-operative from a left hip hemiarthroplasty performed on 3/20/2026. While the resident's two-week follow-up occurred on 3/31/2026, the subsequent six-week follow-up with the surgeon was expected mid-May 2026.On 06/17/2026 at 1:27 PM, the Nursing Home Administrator (NHA) was asked to provide documentation regarding the six-week post-surgery appointment and the resulting consultation report. The NHA stated they were still searching for records of the six-week follow-up but provided the documentation for the two-week post-surgery visit.On 06/18/2026 at 7:21 AM, the NHA provided documentation for the six week follow-up appointment scheduled for 6/24/2026, noting that the order for this appointment was placed on 6/17/2026, the same day the follow-up appointment was requested. The NHA explained that the original appointment was missed because the transporter failed to stop at the nurse's station in the doctor's office to schedule it. The NHA acknowledged that the failure to schedule the six-week follow-up for Resident #15 in a timely manner was an issue.

Based on observation and interview, it was determined that the facility failed to ensure finger nail care was provided to residents. This was evident for 3 (Resident #4, #8, #55) of 34 residents observed during the initial pool process of the annual survey.The findings include:1) On 06/15/2026 at 8:03 AM, an observation of Resident #55 revealed that their finger nails were long.At the same time, an interview with the resident revealed that they agreed they were long and that staff do not cut them down.On 06/17/2026 at 9:55 AM, an interview with Resident #55 revealed their nails were still long and the resident indicated they weren't able to open anything up with their nails being so long.2) On 06/15/2026 at 8:14 AM, an observation of Resident #8 revealed their finger nails were long. On 06/17/2026 9:55 AM, an interview with the resident revealed they felt their nails were long and would like for them to be cut down.3) On 06/15/2026 at 10:42 AM, an observation of Resident #4 revealed their finger nails were long and were dirty underneath (dark substance). On 06/16/2026 at 10:47 AM, an observation of Resident #4 revealed their finger nails were the same as the observation above. On 06/17/2026 at approximately 11:57 AM, an interview with the Director of Nursing revealed that nurses and geriatric nursing assistants were expected to monitor finger nails and trim them as needed with Activities of Daily Living (ADL) care. The surveyor reviewed the concern.

Based on observation, clinical record review and interviews, it was determined that the facility failed to ensure that dependent residents' grooming needs were met. This was evident in 1 (Resident #162) of 8 resident reviewed for Activities of Daily Living (ADL). The findings include: Resident #162's diagnoses included Hemiplegia and Hemiparesis following Cerebral Infraction affecting Left non-dominant side and Aphasia and Cognitive Communication Deficits. On 06/15/26 at 07:42 AM the surveyor observed Resident #162 lying in bed with facial hair covering his/her upper lip.A review of the resident's clinical record on 06/15/26 at 11:24 AM revealed a Quarterly MDS (ARD 03/25/26) which indicated impairment in upper and lower extremities, with a functional status of Dependent for personal hygiene. The clinical record failed to reveal evidence that Resident #162 refused to be shaved.On 06/15/26 at 12:55 PM in an interview RN# 35 stated that that due to the resident's medical condition, the resident was incapable of taking care of his/her personal hygiene which included grooming and was dependent on staff. RN #35 accompanied the surveyor to Resident #162's room, confirmed the findings and stated that it was the Geriatric Nursing Assistant's responsibility to ensure the resident was groomed and that she would address the matter.On 06/16/26 at 8:20 AM, after the surveyor's intervention, Resident #162 was observed lying in bed well-groomed and clean shaven.The Director of Nursing was notified of the surveyor's findings on 06/16/26 at 12:46 PM.

Based on record review and staff interviews, it was determined that the facility staff failed to ensure necessary treatment and interventions were implemented to promote the healing for an existing pressure ulcer. This deficient practice was evident for 1 (Resident #84) of 4 residents reviewed for pressure ulcers during the annual survey.The findings include:A review of Resident #84's medical record on 06/18/2026 at 2:00 PM, revealed the resident was readmitted to the facility on [DATE] with an identified stage 2 pressure ulcer. On 03/30/2026, a consulted Wound Care Nurse Practitioner (NP) recommended daily and as-needed wound treatments. The Wound Care NP assessed the residents' wound weekly. On 04/20/2026, the NP's weekly assessments indicated the wound had increased in size since admission and ordered the treatment frequency increased to twice per day and as needed. A review of the residents' Treatment Administration Record (TAR) failed to reveal an order for twice-per-day wound care treatment. Further review of the medical record revealed that despite weekly assessments indicating a worsening of the wound until 04/27/2026, a pressure-reduction mattress was not ordered until 04/24/2026.On 06/22/2026 at 8:44 AM, during an interview with Wound Care Nurse #9, she stated that the Wound Care NP conducts weekly assessments, discusses treatment plans with her directly, and emails weekly assessment reports to her and the Director of Nursing (DON). The surveyor inquired about the failure to increase Resident #84's wound care frequency to twice daily per the NP's recommendation, the Wound Care Nurse #9 acknowledged that she had overlooked the order. The surveyor also inquired about the delayed implementation of a pressure reduction mattress, which was not ordered until 04/24/2026 despite recorded evidence of a worsening pressure ulcer; the Wound Care Nurse #9 provided no response. The surveyor discussed these concerns with the DON, who acknowledged the findings.

Based on record review and staff interviews, it was determined that facility staff failed to ensure a certified nursing assistant-1 (CNA-1) maintained an active certification. This deficient practice was evident in 1 out of 5 CNA-1 employee files reviewed during the annual survey.The findings include:A review of CNA-1 #26's employee file on 06/22/26 revealed a pending CNA-1 certification.On 06/22/2026 at 12:41PM, the surveyor informed the Director of Nursing (DON) and Human Resource (HR) #20 of the pending status and requested documentation indicating CNA-1 #26 had an active certification. HR #20 stated she could only verify a pending certification as of 03/05/2026 based on Maryland Board of Nursing records. HR #20 further confirmed that CNA-1 #26 had worked at the facility with a pending certification since 03/16/2026, and most recently worked a shift on 06/18/2026.

Based on record review and staff interviews, it was determined that the facility staff failed to ensure an annual performance review was conducted at least every 12 months. This deficient practice was evident for 1 of 5 Certified Nursing Assistant-1 (CNA-1) employee files reviewed for annual performance reviews during the annual survey.The findings include:On 06/22/2026 at 9:41 AM, a review of CNA-1 #28's employee file revealed a hire date of April 2025. Further review of the employee file failed to show evidence of a 2026 annual performance review.The surveyor informed the Director of Nursing (DON) of the missing performance review; the DON stated she would investigate with human resources and follow up.During an interview Human Resources (HR) #20, on 06/22/2026 at 12:41 PM, regarding the missing evaluation, HR #20 explained that because the CNA-1 is a union employee, facility records indicated the performance review was not due until September 2026. The surveyor explained to the DON and HR #20, that based on the CNA-1's hire date of April 2025, the review must be completed on or before April 2026.

Based on observation, staff interview, and surveyor record review it was determined that the facility failed to ensure that Resident medications were locked and secured properly. This finding was found to be evident in 1(Resident #74) out of 31 Residents reviewed for labeling and storage of medications.The findings include:At 9:05 AM on 6/15/2026 the surveyor observed a plastic medication cup sitting on the overbed table in Resident #74's room. In the medication cup were 2 tablets, a round peach colored tablet and an oblong white colored tablet. Resident #74 was observed alert, in bed eating breakfast. The surveyor stood at the entrance to Resident #74's door and asked Licensed Practical Nurse (LPN) #4 to come into the room. LPN #4 observed the medication cup with two (2) tablets on Resident #74's overbed table. LPN #4 took the medication cup from the overbed table. In an interview with LPN #4 she stated that the medications should not be at Resident #74's bedside and that she would follow up.Self-Administration of medication is the process where a Resident independently prepares and takes their own prescribed medications. This requires both motor skills to handle the medication and cognitive awareness for understanding the medication. An assessment is completed by the clinical team to determine if Resident can administer his/her own medications and there is a Resident care plan for self-administration of medications.Care Plan in long term care is a personalized, written roadmap detailing how a Resident's medical, physical, and emotional needs will be met. It translates health assessments into measurable goals, assigned services, and daily interventions, ensuring staff provide safe, consistent care. Key components addressed in the care plan include medical and medication management which include specific interventions for medication regimens.The surveyor conducted a record review at 10:05 AM on 6/16/2026 of Resident #74's medical record. Record review revealed that Resident #74 did not have a physician order for self-administration of medications. Additionally, there was not an assessment or a care plan for self-administration of medications. Review of Resident #74's physician medication orders revealed the following medications Amlodipine (high blood pressure-hypertension), Ezetimibe (for high cholesterol-hyperlipemia) Farxiga (chronic kidney disease, diabetes, heart failure), Lasix (water pill-diuretic), Lipitor (high cholesterol-hyperlipidemia), Metoprolol (high blood pressure-hypertension), Oxybutynin (urinary urgency), and Vitamin D3 (vitamin D deficiency).In an interview with the Licensed Nursing Home Administrator (LNHA) on 6/16/2026 at 10:50 AM the surveyor requested a copy of the facility's medication storage policy and procedure. Additionally, the surveyor updated the LNHA on the concern with medications observed at the bedside for Resident #74 on day one (1) of the survey and he stated that he was aware as he was notified by the staff.The surveyor reviewed on 6/16/2026 at 12:30 PM the facility's Storage of Medications policy and procedure dated 9/2018 with a revision date of 8/2024. The policy indicated that medications and biologicals are stored safely, securely and properly following manufacturers' recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. All medications dispensed by the pharmacy are stored in the pharmacy container with the pharmacy label. At the time of survey exit, no additional information was provided by the facility.

Based on interviews and record review, it was determined that the facility failed to ensure that a dental appointment was made for a resident following a physician's consult request. This was evident for 1 (Resident #45) of 4 residents reviewed for dental services.The findings include:During an interview on 06/15/26 at 9:05 AM, Resident #45 reported experiencing a toothache. They expressed dissatisfaction, noting that despite notifying nursing staff of the issue two days earlier, they had not yet been evaluated by a dentist.A review of Resident 45's clinical record on 06/16/26 11:05AM revealed the resident complained of toothache on 6/12/26 and as of that date, had been receiving pain medications and antibiotics for tooth infection as ordered by the physician. A Dental Consult was also ordered by the physician on 6/12/26. Further review of the clinical record revealed no evidence of a scheduled dental appointment or any attempts to secure one.On 06/17/26 at 8:21 AM in an interview RN #35 stated that the facility's in-house dentist visited on 06/15/26, (3 days after the resident's complaint) but the resident was not seen by that dentist because he/she was not on the list of residents to be seen. Further, when asked whether the resident had an appointment to see a dentist, the staff stated that she could not find documentation of one in the resident's clinical record.On 6/17/26 at 9:10 AM the Director of Nursing (DON) stated that the in-house dentist was in the facility on 06/15/26 but did not explain why Resident #45 was not placed on the list to be seen. The surveyor enquired about the dental consult in keeping with the physician's order. The DON stated that she would check the records. On 06/17/26 at 11:00 AM the DON provided the surveyor with a copy of an email to a dental provider requesting an appointment for Resident #45. The surveyor noted that the email was sent on 06/17/26 at 10:31 AM to the dental provider, after the surveyor's intervention.

Based on observation and interview, the facility failed to ensure food was served at a palatable temperature. This was evident during 1 of 1 test meal tray completed during the annual survey.The findings include:On 06/18/2026 at 8:28 AM, the surveyor observed the breakfast trayline start.On 06/18/2026 at 9:21 AM, the surveyor test tray was plated, prepared, and placed on the meal tray cart.On 06/18/2026 at 9:31 AM, the temperature of the surveyor test tray food was taken. The hot cereal (cream of wheat) was 114.4 degrees fahrenheit. On 06/18/2026 at 9:35 AM, the surveyor tested the hot cereal which was room temperature to taste.On 06/18/2026 at 10:16 AM, an interview with the Dietary Manager revealed the hot cereal should be hot. The surveyor reviewed the concern.

Based on record observation, record review and interview, it was determined that the facility failed to provide documentation of a physician's order for oral suctioning of a resident. This was evident for 1 (Resident #3) of 1 resident reviewed for oral suctioning.The findings include:On 06/15/26 at 8:27 AM a suction machine, with white liquid in its canister indicating that the machine had been used, was observed at the resident's bedside. LPN #34 stated that the machine was used for oral suctioning of Resident #3.A review of the clinical record on 06/16/26 revealed that Resident #3 was suctioned on 05/02/26. The progress note stated 5/2/2026 23:08 Note Text: . G-tube patent and intact, site cleaned as ordered. Oral care was provided and suction. Further review of the clinical record failed to reveal evidence of a physician's order for suctioning of the resident.On 06/16/26 at 12:36 PM in an interview the Director of Nursing (DON) stated that it was the expectation for the nurse to obtain a physician's order for suctioning and that she would review the records.On 06/16/26 at 1:46 PM the DON stated that the resident's clinical record was updated and that the omission of the physician's order was an oversight.

Based on review of the Quality Assurance and Performance Improvement (QAPI) Program plan and interview with facility staff, it was determined that the facility failed to provide documentation from the Dietician regarding the development, implementation, and evaluation of corrective actions or performance improvement activities for the resident's nutritional needs. This deficient practice was evident during the annual survey. The findings include:On 06/22/2026 at 8:29 AM, a request was made for the QAPI committee's quarterly calendar, meeting minutes, and sign-in sheets.On 06/22/2026 at 9:50 AM, the Quality Assurance (QA) Registered Nurse (Staff #29) was interviewed regarding the QAPI meeting process. Staff #29 explained that prior to monthly meetings, all department heads submit data from the previous month. During the meeting, the team discusses this data to identify issues, determine corrective actions, and assign responsibility for those corrections.On 06/22/2026 at 11:57 AM, a review of the monthly QAPI minutes revealed that while other departments provided data, there was no documentation from the Dietitian regarding interventions for weight gain, weight loss, or residents' overall nutritional needs.On 06/22/2026 at 12:00 PM, Staff #29 was asked to provide the Dietitian's QAPI data from December 2025 to April 2026. Staff #29 stated, I do not put the Dietitian data in my QAPI notes. When asked how the Interdisciplinary Team (IDT)-which consists of all department heads-tracks and evaluates residents' weight changes without input from the Dietitian, Staff #29 indicated they would consult the Director of Nursing (DON). Also, on 06/22/2026 at 12:00 PM, a review of the facility's QAPI policy confirmed that committee members must include the Administrator, Director of Nursing, Medical Director, Infection Preventionist, a Dietitian-nutritionist, a Social Worker, and a Geriatric Nursing Assistant. A review of attendance records from December 2025 through April 2026 showed the following:12/19/2025: Dietitian was absent.1/16/2026 and 2/20/2026: Dietitian attended virtually.3/20/2026: Dietitian attended the meeting.4/24/2026: Dietitian was on medical leave.Reviewing the data revealed no Dietitian documentation regarding weight or overall nutritional status was in the monthly QAPI data for December 2025 through April 2026. Furthermore, the QAPI minutes for March/ April 2026 noted that residents reported they still had not met with the Dietitian and were told the facility was working on this issue.On 06/22/2026 at 12:15 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were asked again to provide documentation confirming the Dietitian evaluations of residents' weights and nutrition. The DON stated she would check her emails.On 06/22/2026 at 12:31 PM, the NHA, the DON, and the QA nurse were unable to provide any documentation from the monthly QAPI meetings held between December 2025 and April 2026 that included recommendations from the Dietitian regarding resident weights or nutritional needs. No additional documents were provided to show that the Dietitian had contributed input during the monthly QAPI meetings. No additional information was provided by the facility at the time of exit.

Based on a review of facility documentation, facility policies, and staff interviews, it was determined that the facility's Dietitian failed to participate in the quarterly Quality Assurance and Performance Improvement (QAPI) committee meetings. This was evident for two of the four quarterly meeting records reviewed during the annual survey.The findings include: On 06/22/2026 at 8:29 AM the QAPI committee quarterly calendar was requested as well as the QAPI committee meeting minutes and the attendance record.On 06/22/2026 at 8:39 AM, the Nursing Home Administrator (NHA) was interviewed and the QAPI attendance records were reviewed with them. The records showed that the Dietician, Staff # 30, was absent from the quarterly meetings held on 8/22/2025 and 11/14/2025. The NHA explained that Staff #30 was on medical leave at some point and that a different Dietician was supposed to cover for them. I asked the NHA to provide documentation showing that a replacement Dietician attended these meetings. The NHA agreed to investigate and follow up.On 06/22/2026 at 9:50 AM, the Quality Assurance (QA) Registered Nurse, Staff # 29, was interviewed regarding the QAPI meeting process. Staff #29 explained that before each monthly meeting, department heads submitted their data for the previous month. Then during the QAPI meeting the group discussed any issues, determines corrective actions, and assigns responsibility for those corrective actions from the data submitted. When asked about collecting signatures, Staff #29 stated they usually ensure all attendees sign the attendance sheet at the end of the QAPI meeting; if someone is attending virtually, Staff #29 signs their name for them. I showed Staff #29 the attendance sheets for several months and asked for documentation confirming who represented the Dietician at the meetings on 8/22/2025 and 11/14/2025. Staff #29 stated they did not have any documentation regarding this and could not recall the name of the replacement Dietician. I informed Staff #29 that this was a concern, and they acknowledged understanding that not being able to provide documentation the Dietician attended the [NAME] QAPI meetings was an issue. No additional information was provided by the facility at the time of exit.

Based on observations and staff interviews it was determined that the facility failed to maintain infection control practices. This finding was found to be evident in review of the physical environment of the nursing unit and laundry room during the annual recertification survey.The findings include: 1) On entrance to the facility as the survey team was being escorted to the conference room at 7:05 AM on 6/15/2026 by Registered Nurse (RN) #7 observed were three (3) plastic bags of trash/linen resting directly on the floor in the hallway of the [NAME] Wing nursing unit outside of Resident rooms 49, 51 and 52. The surveyor asked RN #7 what the expectation was for trash/linen on the floors in the hall and RN #7 stated that the bags of linen/trash should not be on the floors, and proceeded to speak with the nursing staff. At 7:35 AM on 6/15/2026 a portable ice cart was observed outside of the kitchen, and the ice scoop was observed not covered and lying on the shelf of the portable ice cart. On 6/18/2026 at 3:20 PM the surveyor observed a portable ice chest in the hall outside of room [ROOM NUMBER] on East Wing nursing unit and the ice scoop was observed in the ice chest that was 1/2 full of ice. Licensed Practical Nurses (LPN) #10 and #11 were standing next to the medication cart that was adjacent to the portable ice chest. LPN #10 acknowledged the surveyor and indicated that he was distributing ice to the Residents. At 3:40 PM on 6/18/2026 the surveyor met the Licensed Nursing Home Administrator (LNHA) in the hall and LNHA stated that LPN #10 told him that the ice scoop was observed in the ice chest by the surveyor. The surveyor conveyed to the LNHA that this was the 2nd time that a concern with the portable ice cart was identified. 2) The surveyor observed the laundry room at 7:10 AM on 6/22/2026 with the Environmental Services Director (EVS) in attendance. In the clean linen folding room there was a refrigerator observed with employees' food items and beverages, a bag of Hershey chocolates 1/2 full on top of the refrigerator, a supply of plastic cups and utensils in a caddy on the shelf underneath the folding table, and a gray lunch bag on the shelf. In the dryer area on the stationary metal shelf (bottom shelf), observed an open bottle of water ¾ full with a date on the cap and several full bottles of water. EVS Director stated that these water bottles belonged to the laundry staff. The surveyor conveyed to the EVS Director after tour of the laundry areas on 6/22/2026 the concerns with infection control in the folding room and dryer room with staff personal food and beverage items. No additional information was provided by the facility at the time of survey exit. 3) Resident #3 diagnoses include Dysphagia following Cerebral Infraction and Gastrostomy Status. On 06/15/26 at 8:27 AM the surveyor observed the following equipment at the resident's bedside: An Oxygen concentrator in operation, with scattered spots of brown material covering the front of the machine. An IV pole with a bottle of tube feeding hanging at the top of the pole. On the base of the pole were large patches of crusted yellow material. A suction machine with white liquid in its canister. On the vent area, at the top of the suction machine, was scattered white dust like material. On 06/15/26 at 8:47 AM, LPN #34 accompanied the surveyor to Resident 3's room and confirmed the findings. In an interview, LPN #34 stated that the licensed nurses were responsible for ensuring that the resident's equipment remained clean during every shift. However, the night shift was mainly responsible for the cleaning. A review of the resident's clinical record on 06/16/26 at 9:52 AM revealed that the resident was dependent on Gastrostomy feeding for nutritional needs and supplemental oxygen via concentrator for respiratory needs. During an interview on 06/16/26 at 12:40 PM the Director of Nursing was notified and did not comment on the surveyor's findings.

Based on record review, observation, and interview with residents and staff, and other pertinent documents it was determined that the facility subjected residents to involuntary seclusion by restricting their ability to move freely. This was evident for 4 (Resident #17, #30, #102, #108) out of 15 residents residing in the locked area of the Med Bridge unit. Additionally, due to the restriction, Resident #108 experienced distress resulting in self-inflicted physical harm in an attempt to exit the locked unit. As a result of the non-compliance an IJ (Immediate Jeopardy) was determined on 4/25/2025 at 3:30 PM. An IJ summary tool was provided to the facility on 4/25/25. The facility submitted a draft of their plan to remove the immediacy on 4/25/25 at 6:40pm, and it was not accepted. The facility submitted a second draft of their plan to remove the immediacy on 4/25/25 at 7:45pm and it was accepted by the State Agency on 4/25/2025 at 8:00pm. After removal of the immediacy, the deficient practice remained with a scope and severity of E. The Immediate Jeopardy was removed on 4/29/25 after on-site confirmation of the completion of the facility's plan of removal. The findings include: During an interview with the NHA (Nursing Home Administrator), the ADON (Assistant Director of Nursing) and Staff #2 on 4/16/25 at 1:11pm, Staff #2 stated that the locked unit was initiated on 10/31/24 following an elopement incident involving a resident. At the time of the interview, the door to the unit was unlocked and opened and remained that way during the rest of the survey. During record review on 4/25/25 at 11:40am, it was revealed that Resident #108 was observed by staff banging on the double doors of the locked portion of the Med Bridge unit on 11/6/24 at 7:00am. At 4:04pm, the resident had an X-ray performed which showed acute fractures of the distal radius and ulnar styloid. The resident was sent to the hospital on [DATE] for immobilization of the fractures. Prior to this incident, there had been no documentation to indicate Resident #108 had demonstrated similar behavior of banging on doors. During observation rounds on 4/16/25 at 7:56am, 15 residents were observed to be behind a locked door when the surveyor conducted an initial tour of the facility. The surveyor questioned the unit manager (Staff #18) regarding the lock unit. Staff #18 stated the locked door was not actually a locked unit and that it was part of a skilled unit. On 4/23/25 at 02:48pm, Staff #2 was interviewed for follow-up information regarding the decision to lock part of the Med Bridge unit. Staff #2 stated that the VPO (Vice President of Operations) initiated the locked portion of the unit as a temporary makeshift unit for the wandering residents. Brief Interview for Mental Status (BIMS) is an assessment tool used to screen and identify resident cognitive status. Scores of 8-12 indicate moderate cognitive impairment, scores of 13 or above indicate cognition is intact. BIMS scores were reviewed for all the residents residing in the locked area on 4/16/25. Three residents (#17, #30, #102) were identified to have BIMS scores above 11 indicating they would be interviewable. On 4/24/25 at 12:20 pm, interviews were conducted with the alert and oriented residents residing on the unit on 4/16/25 when the unit was found to be locked by the State Agency surveyors. Residents #17, #30, and #102 all stated they did not have the code to open the door and that when they needed to go off the unit that staff had to open the door for them. There was no evidence or documentation to indicate these residents needed to reside on a secure locked unit. The other 11 residents on the unit were determined to be not interviewable by review of their BIMS scores and had no documentation in their medical records indicating that they needed a locked unit for their safety. An immediate jeopardy was declared on 4/25/2025. The provision of the plan to remove the immediacy had a completion date of 4/25/25 and included the following: 1. The keypad on the doors was immediately disabled/deactivated and has remained open since 4/16/25 2. All residents in the facility, especially those who wander, have the potential to be affected. No doors in the facility except the door in question has a keypad. The keypad was deactivated on 4/16/25. 3. All double doors in resident care areas do not have keypad/unable to be locked except the doors referenced in this citation, which has been deactivated since 4/16/25. Residents who are noted to be wanderers are being monitored/redirected to their floors/units by the facility staff. All staff to be educated on resident's rights related to freedom from unnecessary restraint and seclusion. Training/in- service to be completed by 4/25/25 4. The facility administrator conducted an audit of all double doors in the resident care areas and no deficiency noted. This audit will continue daily x 4 weeks, weekly x 4 weeks and monthly x 3 months. Results of these audits will be submitted to the QA/QAPI committee for further recommendation(s)

4a. Record review of Resident #23's medical record on 4/16/25 at 10:15 AM revealed a smoking care plan was initiated on 7/27/22 and revised on 2/5/25. It indicated the resident was a dependent smoker with the goal to monitor any issues or complications and assist the resident during smoking times. Additionally, on 5/22/23 a focus area was added to the care plan that the resident was non-compliant with wearing the recommended smoking vest and following the facility smoking policy; however, the goals and/or interventions did not address the resident's noncompliance. During observation rounds 4/16/25 at 9am resident #23 was observed reclining back in the wheelchair in the courtyard located on the first floor. The resident was observed with a lit cigarette hanging from his/her mouth and was unsupervised. On 4/17/25 at 8am Resident #23 was again observed by this surveyor in the upper level courtyard with his/her wheelchair reclined back. Resident #36 walked over to Resident #23 and put a lit cigarette in his/her mouth. At that time the Administrator was walking in the hall and verified the findings. The Administrator stated Resident #36 should not be giving Resident #23 or any other resident a cigarette. Review of Resident #36's record revealed s/he was assessed as being an independent smoker with a BIMs of 9 (moderately cognitive impaired). 4b. Review of Resident #125's medical record on 4/16/25 at 11am revealed the resident has a BIMs (brief interview of mental status) score of 7, (0-7 indicates severe cognitive impairment) as of 4/15/25. Continued review of the medical record revealed a Smoking-Safety Screen dated 2/4/25 assessing the resident as being an independent smoker. Resident #125 was observed ambulating back and forth in the upper level (1st floor) courtyard with a lit cigarette in his/her hand and was unsupervised. During an interview on 4/16/25 at 9:15am the Administrator and the Acting Director of Nursing were made aware of the observation. Both stated that dependent smoking residents should be monitored and should be going downstairs to the courtyard to smoke. It was verified by Both the Administrator and the ADON that resident #125 had been assessed as being a dependent smoker. During an interview with the Activities Director on 4/16/25 at 9:30am, she stated that she has spoken to residents on several occasions about lighting dependent resident cigarettes. She stated Resident #23 was non-compliant with the smoking policy and has been told several times that the dependent residents are to smoke in the downstairs courtyard where they can be supervised. Based on record reviews, observations, and interviews with staff and residents, it was determined that the facility failed to:1) ensure a system was in place to prevent exit seeking residents from leaving the facility unsupervised. This was evident for 2 (Resident #105 and Resident #154) out of 22 residents reviewed for exit seeking; 2) Assess, Supervise and monitor residents while smoking. This was evident for 4 (Resident #106, #23, #125, and #51) out of 22 residents reviewed for smoking; 3) Assess and monitor residents with known wandering behaviors. This was evident for 1 (Resident # 108) out of 25 residents reviewed for wandering. As a result of this deficient practice, an Immediate Jeopardy was identified on 4/25/2025 at 9:10 PM. An IJ summary tool was provided to the facility on 4/25/2025. The facility submitted the first plan to remove the Immediacy on 4/25/2025 at 11:18PM. The first plan was not accepted. The facility submitted a 2nd plan to remove the Immediacy on 4/26/2025 at 2:01AM. The 2nd plan was not accepted. The facility submitted a 3rd plan to remove the Immediacy on 4/26/2025 at 3:21AM. The 3rd plan was not accepted. The facility submitted a 4th plan to remove the immediacy on 4/26/2025 at 3:55AM which was accepted at 4:22AM. After removal of the immediacy, the deficient practice remained with a scope and severity of E. The Immediate Jeopardy was removed on 4/29/25 at 3:15 PM after on-site confirmation of the completion of the facility's plan of removal. The Findings Include: Wandering is a pattern of aimless and often repetitive walking that significantly increases the risk of injury to the individual. Elopement or exit seeking risk are those who are at risk for leaving a place unnoticed and unsupervised. 1. On 04/18/25 at 9:20 AM, a review of resident #154's medical record and facility investigation revealed a care plan focus area, created on 07/29/2022, stated that resident #154 has a risk for elopement and patient wanders related to Impaired Safety Awareness. The resident had a Brief Interview for Mental Status (BIMS) score of 02/15 on 10/21/2024, which indicated the resident was severely cognitively impaired. Further review of an Elopement Risk Tool assessment dated [DATE] revealed resident #154 was a high risk for elopement and exit seeking. A care plan focus area, created on 10/22/2024, stated the resident was at risk for elopement related to dementia and the patient wears a wander guard. On 04/18/2025 at 10:00 AM a review of the facility investigation revealed that on 10/30/2024 approximately. 4:34 PM the facility was first made aware when a phone call from hospital alerting them that resident #154 was found and brought to the emergency room by Emergency Medical Services (EMS). EMS received a call from someone in the community that resident #154 was on their property, EMS responded and took the resident to the Emergency Room. Per facility investigation on 10/30/2024 the resident was last seen by Nurse staff #20 at 2:00 PM standing in the hallway of the unit. Staff #20 said he heard the back door alarm go off and responded immediately with other staff members and they went outside the door but did not see anyone, the alarm was deactivated and staff returned to the unit. The investigation revealed that the staff did not take any additional steps to validate that Resident #154 was still on the unit and in the facility. Further review of resident #154's medical record and facility investigation revealed that on 10/30/2024 at 7:30 PM Resident #154 returned to the facility from the emergency room and the Nurse Supervisor verified that the resident was wearing a wander guard, staff completed an assessment on resident and determined that resident had no injuries, facility placed a one on one caregiver with resident upon return to the facility. On 04/22/2025 at 12:09 PM during an interview - Regional Consult for Clinical staff #2 stated on 10/30/2024, day of the elopement, it was on the downstairs unit, 2-3 staff members went through the first door on the unit leading to the stairwell to go to a training on another unit upstairs. The door closed and shortly after Resident # 154 went through the first door entering the stairwell, then Resident #154 went to the left and went through the second door that leads to the outside and staff responded to the alarm, they looked around outside and did not see anyone and came back into the center. On 04/22/2025 at 1:45 PM during observation rounds of facility and interview with Maintenance Director staff #13, Assistant Director of Nursing staff #11 and Regional Consult for Clinical staff #2, the Maintenance Director stated the doors that Resident #154 eloped from were located on the lower level of the facility near room [ROOM NUMBER]. After the elopement of Resident #154 the keypad, release button on the inside of stairwell door and wander guard system leading out the first door into the stairwell was noted to be broken. The wander guard system only works if the resident is wearing a wander guard and presses the door handle. The second door that the resident went through leading to the outside of the building had not been connected to the fire alarm system but will now open and alarm only when the fire alarm is alarming. At the time of rounds the first door leading to the stairwell did alarm when the door was pressed while holding a wander guard device near the door and the second door was noted to be locked and able to be opened only by using the keypad with a code. On 04/23/2025 at 9:48 AM during observation rounds with Maintenance Director staff #13 and Nursing Home Administrator staff # 1 revealed the wander guard systems did not alarm when a wander guard device was placed next to the doors which demonstrated that the wander guard system was not working for the following doors: a. the upper East Wing door, b. the lower level East Terrace door next to the physical therapy room, c. the lower level East Terrace door between physical therapy room and DON office, d. the upper level Main Dining Room door and the upper level door next to the Dietician office 2. On 4/22/2025 at 11:00AM, a review of Resident #105's electronic medical record revealed that the resident was admitted to the facility on [DATE] with a diagnosis of but not limited to dementia and anxiety. The resident had a Brief Interview for Mental Status (BIMS) score was 13/15, which indicated the resident was cognitively intact. There was a care plan focus created on 4/25/2023, which stated that the resident wanders related to impaired safety awareness secondary to Dementia. Further review revealed an admission Elopement Risk Assessment on 4/24/2023 which indicated the resident was at a high risk for elopement/exit seeking. The resident had physician orders dated 10/5/2023 for a wander guard on the right wrist, to check function weekly every day shift on Wednesdays, and to check placement every day, every shift and a quarterly Elopement Risk Assessment on 10/27/2023 which indicated the resident was at risk for elopement/exit seeking. On 4/22/2025 at 10:45AM, a review of a facility reported incident (FRI) investigative file revealed that on 1/10/2024 at approximately 9PM, Resident #105 and a visitor were allowed out of the building by a Geriatric Nursing Assistant (GNA) staff member. The GNA staff member assumed the resident was going on a leave of absence with a family member. The GNA turned off the wander guard alarm at the main entrance door after the resident's wander guard triggered the alarm. Further review of the FRI revealed that on 1/10/2024 at approximately 9:24PM, Resident #105 was returned to the facility accompanied by two police officers who saw the resident walking along the sidewalk down the street from the facility. The resident informed the officers that he/she resided at the facility and did not go out and wanted to take a walk. The resident sustained no injuries. 3. On 4/18/2025 at 7:37AM a review of the facility's current smokers list as of 4/7/2025, revealed Resident #106 was an independent smoker, indicating the resident did not need to be supervised while smoking. During review of Resident #106's electronic medical record, the Surveyor discovered a quarterly smoking safety screen assessments with scores. Scores of 0-4 mean the resident may smoke unsupervised and scores 5 or greater means the resident requires supervision with smoking. Resident #106 was assessed as a smoker and had a smoking safety screen score of 0 on 4/17/2024, score of 7 on 7/17/2024, and a score of 2 on 10/18/2024. On a 1/20/2025 smoking safety screen assessment it documented the resident did not smoke and had a score of zero. Further review of the electronic medical record revealed a care plan created on 4/14/2023 and updated on 3/26/2025 with a focus which stated the resident prefers to smoke with interventions for nursing staff to complete a smoking assessment as needed and all staff to supervise with smoking. On 4/18/2025 at 7:00AM, the Surveyor observed Resident #23 and Resident #125 in the upper-level courtyard smoking unsupervised. On 4/18/2025 at 7:50AM during an interview with Activity Director #12, the Surveyors were informed that she does the smoking assessments and that the nursing staff should follow up with them. 6. On 4/22/25 at 11:11 AM, during review of the medical record for Resident #108, the resident's care plan from 5/4/24 read as follows [Resident 108] is an elopement risk/wanderer related to impaired safety awareness. The following interventions were in place Monitor the resident while on the unit as indicated, Redirect the resident as needed. These interventions were in place to prevent Resident #108 from wandering into areas that could lead to an unsafe situation. Review of the previous care plans for Resident #108 showed that he/she was identified as a wanderer since being admitted in April 2023. The prior care plans were dated 5/9/23, 8/8/23 and 11/6/23 and all identified Resident #108 as a wanderer. On 4/24/25 at 2:19pm, review of the progress notes for Resident #108 revealed that on 5/21/24 the resident had wandered into Resident #154's room and when asked to leave, Resident #108 took his/her shoe and threatened to hit Resident #154. Staff separated the residents and took Resident #108 back to his/her room. The resident care plan was not updated with any additional interventions after this incident. The facility's investigation related to facility-reported incident MD00206662 was reviewed on 4/22/25 at 10:17 AM. In the investigation, the facility substantiated there was an altercation on 6/13/24 between Resident #108 and Resident #19. The investigation revealed that Resident #108 wandered into Resident #19's room. Resident #19, unable to call for help due to their medical condition, attempted to go into the hall for assistance and used an emergency whistle to get attention from staff. When no one came to assist, Resident #19 felt he/she was in danger and pepper sprayed Resident #108. Resident #108 had a BIMS (Brief Interview for Mental Status) score of 0 on the most recent assessment dated [DATE] prior to this incident. BIMS scores of 0-7 indicate severe cognitive impairment. Resident #108 was found by staff screaming and holding his/her hands over his/her eyes. The resident was evaluated by the physician at the facility and was ordered to be sent for further evaluation at the hospital. The resident was diagnosed with chemical burns of the eyes at the hospital and was prescribed eye drops for 5 days. On 4/23/25 at 01:40pm, an interview with Resident #19 was conducted. He/she stated that the incident with Resident #108 was not the first time that a wandering resident had entered his/her room and that he/she had alerted administration and staff that it was a recurrent problem. He/She also said that he/she was pushed to the floor in the past by another resident who wandered into his/her room. On 4/23/25 at 8:46am, the facility provided 2 more incident reports which involved Resident #108 wandering into other resident rooms. On 10/27/24 Resident #108 wandered into a resident's room and hit the resident with a plastic hanger, which was substantiated by a witness. The corrective actions related to this incident were to conduct staff in-service on close monitoring and redirection of wandering residents. On 12/2/24, Resident #108 was involved in another incident where Resident #108 wandered into a different resident's room and allegedly kicked his/her leg but there were no other witnesses, and the altercation could not be substantiated. The facility's investigation found that staff did not see Resident #108 enter the other resident's room that night and no witnesses could confirm the event occurred. The corrective action for this incident was as follows, [Resident #108] is being monitored by staff. There were no modifications to the interventions in Resident #108's care plan following the incident on 6/13/24. Further review of the progress notes showed that Resident #108 continued to wander into other residents' rooms with documented examples from the dates 11/21/24, 11/27/24, 12/5/24, 12/12/24, 1/2/25, 2/3/25, 2/20/25, 2/23/25, 3/23/25, and 4/19/25. On 4/24/25 at 09:35am, an interview was conducted with the NHA (Nursing Home Administrator) who stated that the expectations for standard practice at this facility were to monitor the wandering residents anytime they are in the hallways. An Immediate Jeopardy was identified on 4/25/2025. The provision of the plan to remove the Immediate Jeopardy immediacy had a completion date of 4/29/2025 and included the following: 1. Resident #154 no longer resides in the facility; Resident #105 still resides in the facility with a wander guard in place, functioning checked and the wander guard functioning properly. 2. Resident #23, #36, #125, and #51 still reside in the facility and will be supervised during smoking activity. a. Resident # 23 will be provided reeducation on the designated smoke areas and times and was provided with the smoking acknowledgment form for compliance. b. Resident #125 will be provided supervision during smoking activity. A designated staff member will be stationed at the upper-level courtyard door. 3. Wander guards are in place and working properly for Resident #141, 121, and #108. Facility staff will supervise both smoking areas located in the upper and lower level of the facility throughout all scheduled smoke times whether dependent or independent. 4. All individuals identified as a smoker, wanderer, or at risk for elopement have the potential to be affected. A facility wide audit was conducted to verify accuracy of assessments for all residents completed by 4/29/2025. 5. All doors with the wander guard system were checked for proper functioning by the vendor on 4/24/2025 and the following was corrected: a. Checked all secure units, lobby, east wing, exit to kitchen, stairwell by lounge, west by central supply, east terrace by smoking area, east terrace by rehab, main dining room, and exit by maintenance shop. Replaced strobe alarm at terrace smoking door. Disconnect door switch to allow alarm to activate. Verify alarms at all remaining doors while approaching the door. 6. All doors with a wander guard system were checked for proper functioning by the Maintenance Director on 4/26/2025 at 12:45AM and confirmed to be functioning properly. 7. All residents with the wander guard bracelets were checked for placement and function on 4/26/25 at 12:45AM. 8. All residents with wandering behavior will be provided monitoring to ensure safety and wellbeing with the use of an individual hourly monitoring log daily to be completed by nursing and care plan reviewed and revised accordingly. 9. To ensure the accuracy and use of appropriate safety devices, the facility will conduct a new assessment on all current wandering and elopement risk residents by 4/29/2025. 10. To accurately determine the level of assistance needed, all smoking residents will receive a new assessment for 4/29/2025. 11. To safeguard residents, staff will be trained on alarm response and thorough search procedures, followed by a headcount to ensure all are present and accounted for by 4/29/2025. 12. For resident safety, a designated staff member will always provide supervision for all residents during scheduled smoking times. Training will be provided to all staff on facility smoke policy by 4/29/2025. 13. All residents identified for wandering, elopement risk, and smoking will have behavior monitoring implemented as needed by 4/29/2025 a. Wander guard device functioning will be checked weekly by central supply b. Wander guard device placement will be checked every shift by the charge nurse and/or the supervisor. 14. 100% audit was conducted of the wander guard door a;arm system and bracelets completed. The Maintenance Director will complete a daily audit on exit doors x4 weeks, weekly audits x4, and monthly audits x3; daily monitoring of the smokers supported with an audit tool will be completed daily by the nursing staff daily x4 weeks, weekly x4 weeks, and monthly x3; Nursing will monitor all wandering residents Q hourly utilizing a monitoring log to ensure safety daily x4 weeks, weekly x4 weeks, and monthly x3; wander guard device placement audit will be conducted daily x4, weekly x4 and monthly x3 by central supply. 15. All results of the audits will be submitted to the QA/QAPI committee for further recommendation (s) monthly and as needed. 5. On 04/25/25 at 01:41 PM, review of resident records revealed that Resident #51's Smoking Safety Screen, dated 4/18/25, indicated that Resident #51 was a smoker, has dexterity problems, cannot use a lighter independently, requires a smoking apron/blanket while smoking, and must be supervised while smoking. On 04/25/2025 at 1:43 PM, review of resident records revealed that Resident #51 has a medical diagnosis of ataxia and muscle weakness. On 04/25/25 at 01:47 PM, review of resident records revealed that Resident #51's care plan indicated that Resident #51 must be supervised while smoking. Resident #51's care plan did not indicate that Resident #51 must use a smoking apron/blanket while smoking. On 04/25/25 at 01:12 PM, during observation rounds on 4/16/25 and 4/17/25, Resident #51 was noted smoking unsupervised. On 04/25/25 at 01:12 PM, during observation rounds on 4/18/25, 4/21/25, 4/22/25, 4/23/25 and 4/24/25 Resident #51 was observed smoking unsupervised without wearing a smoking apron/blanket. On 04/25/25 at 2:18 PM, Activity Director staff #12 was interviewed. During the interview, staff #12 stated that many dependent smoking residents and independent smoking residents are non-compliant with following the smoking policy. Dependent smoking residents have been told several times that they must smoke in the downstairs courtyard where they can be supervised by staff as well as wear a smoking apron/blanket. Staff #12 also stated that they have told independent smokers not to light cigarettes for dependent smokers. On 04/25/25 at 2:49 PM, Resident #51 was interviewed. During the interview, Resident #51 indicated that he/she was aware that they must be supervised by staff and must wear a smoking apron/blanket while smoking.

Based on observations, record review and interviews, it was determined that the facility failed to prevent a cognitively impaired resident with exit seeking behaviors from leaving the facility. This was evident for 1 (Resident#1) out of 1 resident reviewed for accidents. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified verbally and in writing of this determination at 7:15 PM on 01/26/2023. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 12:15 AM on 01/27/2023. The findings include: On 01/26/2023 at approximately 10:27 AM, the survey team had exited the facility after the completion of the environmental survey. At which time the survey team observed 3 County police vehicles and 1 K-9-unit Sports Untility Vehicle (SUV) parked in front of the facility. The Surveyor asked the Director of Nursing (DON) why the police were in the facility, the DON stated he was unsure. During an interview conducted on 01/26/2023 at approximately 10:29 AM, the Surveyor asked the K-9-unit Police Officer #20 why s/he was in the facility. The Police Officer stated, there is a missing resident. During an interview conducted on 01/26/2023 at approximately 10:33 AM, the surveyor asked the DON if he was aware that there was a missing resident. The DON stated when he arrived at the facility at approximately 8:30 AM he was advised that Resident #1 with a diagnosis of dementia was missing and the staff was searching the facility and grounds for the resident. The DON further stated he had just learned the resident exited the facility through the double doors that led to the smoker's courtyard on the bottom floor of the facility. On 01/26/2023 at approximately 10:34 AM the surveyors conducted an observation of the set of two glass double doors where the resident exited the facility. The first set of double glass doors had a fire safety egress statement that read push unit alarm sounds, door can be opened in 15 seconds. On the left wall located near the first set of the glass double doors was a wanderguard sensor and a door alarm system with a keypad. During the continued observation, the Activities Director #10 was observed using a key fob to open the glass double doors to allow the smokers to go outside to the smoker's courtyard. During an interview conducted on 01/26/2023 at approximately 10: 36 AM, the Activities Director #10 stated the glass double doors can either be opened with the key fob or if the door handle is pushed for a period of 15 seconds. She also stated the doors will open automatically if the door handle is pushed for 15 seconds due to the fire safety egress. The Activities Director then pushed the door handle for 15 seconds, the audible door alarm triggered, and both sets of glass double doors opened to the smokers outside courtyard. During the observation of the smoker's courtyard on 01/26/2023 at approximately 10:37 AM, the surveyors observed a 5-foot wooden fence with 3 exit gates. The observation of the gates showed two of the exit gates were secured with zip ties and one gate was secured with a master lock. On 01/26/2023 at approximately 10:50 AM a review of the facility's camera footage revealed the camera's current time was behind by 20 minutes of the actual time. The footage showed the resident had made an unsuccessful attempt to exit the facility from the glass double doors that led to the smokers outside courtyard on 01/26/2023 at 5:19 AM. The resident was seen returning to the same doors and exiting the facility on 01/26/2023 at 5:34 AM. However, the actual real time the resident first attempted to exit the facility occurred on 01/26/2023 at 4:59 AM and the second and successful attempt to exit the facility occurred on 01/26/2023 at 5:14 AM. During an interview conducted on 01/26/2023 at approximately 11:05 AM, the K-9 Police Officer #20 stated the camera footage showed the top of the resident's head on the other side of the 5-foot wooden fence of the smokers' courtyard around 5:36 AM. A medical record review for Resident #1 was conducted on 01/26/2023 at approximately 11:08 AM revealed the resident was diagnosed with Dementia. According to the Centers of Medicare and Medicaid Services (CMS) the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. All assessments are completed within specific guidelines and time frames. In most cases, participants in the assessment process are licensed health care professionals employed by the nursing home. MDS information is transmitted electronically by resident nursing homes to the national MDS database at CMS. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively now. It is a required screening tool used in nursing homes to assess cognition. The resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment. A review of Resident #1's quarterly MDS assessment was conducted on 01/26/2023 at approximately 11:10 AM. The MDS quarterly assessment dated [DATE] revealed the resident's BIMS assessment revealed a score of 9. A continued review of Resident #1's medical records revealed progress notes that stated on 07/29/2022 s/he wanted to go home and attempted to exit the front door. The resident was redirected several times and a wanderguard was placed on the right wrist. Another note dated 08/02/2022 stated the resident attempted to exit the front door and was redirected. Review of Resident #1's elopement risk assessment dated [DATE] indicated the resident scored a nine. A score of 8-9 placed the resident at risk for elopement and exit seeking. A review of Resident #1's care plan initiated on 07/29/2022 showed a care plan for General Safety Risk related to impaired cognition with an intervention for wander alert. Review of the Treatment Administration Record (TAR) revealed documentation that staff checked for placement and functionality for the wanderguard from 01/01/2023 - 01/25/2023. On 01/26/2023 at approximately 11:26 AM the surveyors conducted a second tour of the smoker's courtyard; the surveyors observed 5 residents in the courtyard unsupervised and the zip ties on the right gate now cut and no longer secure. The surveyors were able to freely push the gate open that led to the outside grounds of the facility. During an interview conducted on 01/26/2023 at approximately 11:30 AM, the DON stated the police cut the zip ties to gain entry to the grounds, he also stated he would have maintenance replace the zip ties. The surveyors continued to observe the unmanned and unsecured gate from 11:30 AM to 12:34 PM until the DON provided coverage to supervise the unsecured gate. On 01/26/2023 at approximately 12:35 PM the surveyors observed the DON check the wanderguard system for the double doors that Resident #1 exited. The surveyors observed the door alarm audibly trigger when the door handle was pushed and an audible wanderguard alarm triggered when the DON went through the doors that led to the smokers outside courtyard. The DON confirmed that once the door is alarmed the door can be freely pushed open even while wearing a wanderguard. During the continued tour of the facility on 01/26/2023 at approximately 12:45 PM, the surveyors and DON identified an emergency exit door located on the East Terrace wing that was unlocked. The surveyors pushed on the door handle and the doors freely opened. The doors led to another set of doors that when pushed opened freely to the outside of the facility. The DON called Maintenance Director #13 to come to the East Terrace emergency exit. The Maintenance Director attempted multiple times to lock the doors by putting a code on the keypad located on the wall next to the doors but was unsuccessful. The DON assigned Floor Tech # 8 to guard the emergency exit doors until the door was secure. During an interview conducted on 01/26/2023 at approximately 12:47 PM, the Maintenance Director #13 confirmed he had not performed daily audits on the facility exit doors to ensure they were secure since his employment of about one and half weeks. During an interview conducted on 01/26/2023 at approximately 12:48 PM with the DON and Administrator, the DON stated the last time door audits had been performed were conducted by the previous Maintenance Director. The Administrator stated he would have the door audit logbook located and provided to the surveyor. The door logs were provided to the surveyor and confirmed the last door audit was performed on 12/27/2022. On 01/26/2023 at approximately 1:10 PM the DON advised the surveyors that the emergency exit doors located on the East Terrace had been repaired, were now locked, and the alarm was activated. The DON further stated the wires had been cut inside the panel for the doors that activated the lock and alarm. On 01/26/2023 at approximately 1:35 PM the DON advised the surveyors that the resident had been found on 01/26/2023 at approximately 1:30 PM at the County Mall by the Occupational Therapist #9, who was there to get lunch. Review of the local map of the area revealed the mall was located approximately 1.9 miles from the facility. The Mall's area had heavy traffic areas that included major roadways that had a span of 4 traffic lanes as well as a creek. During an observation on 01/26/2023 at approximately 2:30 PM the DON advised the surveyors that Resident #1's wanderguard was functional at the time of the elopement. The DON then directed Resident #1 to walk to the glass double doors that led to the smokers outside courtyard. The resident walked to the door and attempted to push on the door handle, the door opened, and the audible door alarm was triggered. The double doors opened, and the resident entered through the first set of double doors which triggered an audible wanderguard alarm. The resident diagnosed with dementia, wandering and exit seeking behaviors eloped and had wandered the community for approximately 7 hours before being found. The resident had potential for serious injury, serious harm, or death during that time. The facility provided a plan to remove the immediacy while the surveyors were onsite. An initial plan of removal was submitted to the surveyor team and the Office of Health Care Quality for review on January 26, 2023, at approximately 8:43 PM and was rejected. The 2nd plan of removal was given to the surveyor team and the Office of Health Care Quality for review on January 26, 2023, at approximately 9:34 PM and was rejected. The 3rd plan of removal was given to the surveyor team and the Office of Health Care Quality on January 26, 2023, at approximately 11:07 PM and was rejected. The 4th plan of removal was accepted, and the Immediate Jeopardy was removed on January 27, 2023, at approximately 12:15 AM by the surveyor team and the Office of Health Care Quality. The plan included an audit of all exit doors to ensure the doors are secured and the wanderguard system was functional. The glass double doors that led to the smokers outside courtyard was monitored by an employee throughout each shift until the 15 second fire safety egress was removed by the vendor. The emergency exit door located on the East Terrace Wing was repaired to allow the door to lock and alarm. Mandatory training was conducted for all staff for Elopement and Accident Prevention /Supervision. A process was implemented to identify patterns of residents for elopement risk and accidents to be referred to the Quality Assurance Improvement Plan (QAPI). The plan also included a replacement of the 5-foot wooden fence that enclosed the smokers outside courtyard to a 6 -foot fence. The facility's compliance date for the plan of removal was January 30, 2023. The survey team verified the facility met its date of compliance on January 31, 2023.

Based on observations, record review and interviews, it was determined that the facility failed to prevent a cognitively impaired resident with exit seeking behaviors from leaving the facility. This was evident for 1 (Resident#1) out of 1 resident reviewed for accidents. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy, and the facility was notified verbally and in writing of this determination at 7:15 PM on 01/26/2023. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 12:15 AM on 01/27/2023. The findings include: On 01/26/2023 at approximately 10:27 AM, the survey team had exited the facility after the completion of the environmental survey. At which time the survey team observed 3 County police vehicles and 1 K-9-unit Sports Untility Vehicle (SUV) parked in front of the facility. The Surveyor asked the Director of Nursing (DON) why the police were in the facility, the DON stated he was unsure. During an interview conducted on 01/26/2023 at approximately 10:29 AM, the Surveyor asked the K-9-unit Police Officer #20 why s/he was in the facility. The Police Officer stated, there is a missing resident. During an interview conducted on 01/26/2023 at approximately 10:33 AM, the surveyor asked the DON if he was aware that there was a missing resident. The DON stated when he arrived at the facility at approximately 8:30 AM he was advised that Resident #1 with a diagnosis of dementia was missing and the staff was searching the facility and grounds for the resident. The DON further stated he had just learned the resident exited the facility through the double doors that led to the smoker's courtyard on the bottom floor of the facility. On 01/26/2023 at approximately 10:34 AM the surveyors conducted an observation of the set of two glass double doors where the resident exited the facility. The first set of double glass doors had a fire safety egress statement that read push unit alarm sounds, door can be opened in 15 seconds. On the left wall located near the first set of the glass double doors was a wanderguard sensor and a door alarm system with a keypad. During the continued observation, the Activities Director #10 was observed using a key fob to open the glass double doors to allow the smokers to go outside to the smoker's courtyard. During an interview conducted on 01/26/2023 at approximately 10: 36 AM, the Activities Director #10 stated the glass double doors can either be opened with the key fob or if the door handle is pushed for a period of 15 seconds. She also stated the doors will open automatically if the door handle is pushed for 15 seconds due to the fire safety egress. The Activities Director then pushed the door handle for 15 seconds, the audible door alarm triggered, and both sets of glass double doors opened to the smokers outside courtyard. During the observation of the smoker's courtyard on 01/26/2023 at approximately 10:37 AM, the surveyors observed a 5-foot wooden fence with 3 exit gates. The observation of the gates showed two of the exit gates were secured with zip ties and one gate was secured with a master lock. On 01/26/2023 at approximately 10:50 AM a review of the facility's camera footage revealed the camera's current time was behind by 20 minutes of the actual time. The footage showed the resident had made an unsuccessful attempt to exit the facility from the glass double doors that led to the smokers outside courtyard on 01/26/2023 at 5:19 AM. The resident was seen returning to the same doors and exiting the facility on 01/26/2023 at 5:34 AM. However, the actual real time the resident first attempted to exit the facility occurred on 01/26/2023 at 4:59 AM and the second and successful attempt to exit the facility occurred on 01/26/2023 at 5:14 AM. During an interview conducted on 01/26/2023 at approximately 11:05 AM, the K-9 Police Officer #20 stated the camera footage showed the top of the resident's head on the other side of the 5-foot wooden fence of the smokers' courtyard around 5:36 AM. A medical record review for Resident #1 was conducted on 01/26/2023 at approximately 11:08 AM revealed the resident was diagnosed with Dementia. According to the Centers of Medicare and Medicaid Services (CMS) the Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility, periodically, and on discharge. All assessments are completed within specific guidelines and time frames. In most cases, participants in the assessment process are licensed health care professionals employed by the nursing home. MDS information is transmitted electronically by resident nursing homes to the national MDS database at CMS. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively now. It is a required screening tool used in nursing homes to assess cognition. The resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment. A review of Resident #1's quarterly MDS assessment was conducted on 01/26/2023 at approximately 11:10 AM. The MDS quarterly assessment dated [DATE] revealed the resident's BIMS assessment revealed a score of 9. A continued review of Resident #1's medical records revealed progress notes that stated on 07/29/2022 s/he wanted to go home and attempted to exit the front door. The resident was redirected several times and a wanderguard was placed on the right wrist. Another note dated 08/02/2022 stated the resident attempted to exit the front door and was redirected. Review of Resident #1's elopement risk assessment dated [DATE] indicated the resident scored a nine. A score of 8-9 placed the resident at risk for elopement and exit seeking. A review of Resident #1's care plan initiated on 07/29/2022 showed a care plan for General Safety Risk related to impaired cognition with an intervention for wander alert. Review of the Treatment Administration Record (TAR) revealed documentation that staff checked for placement and functionality for the wanderguard from 01/01/2023 - 01/25/2023. On 01/26/2023 at approximately 11:26 AM the surveyors conducted a second tour of the smoker's courtyard; the surveyors observed 5 residents in the courtyard unsupervised and the zip ties on the right gate now cut and no longer secure. The surveyors were able to freely push the gate open that led to the outside grounds of the facility. During an interview conducted on 01/26/2023 at approximately 11:30 AM, the DON stated the police cut the zip ties to gain entry to the grounds, he also stated he would have maintenance replace the zip ties. The surveyors continued to observe the unmanned and unsecured gate from 11:30 AM to 12:34 PM until the DON provided coverage to supervise the unsecured gate. On 01/26/2023 at approximately 12:35 PM the surveyors observed the DON check the wanderguard system for the double doors that Resident #1 exited. The surveyors observed the door alarm audibly trigger when the door handle was pushed and an audible wanderguard alarm triggered when the DON went through the doors that led to the smokers outside courtyard. The DON confirmed that once the door is alarmed the door can be freely pushed open even while wearing a wanderguard. During the continued tour of the facility on 01/26/2023 at approximately 12:45 PM, the surveyors and DON identified an emergency exit door located on the East Terrace wing that was unlocked. The surveyors pushed on the door handle and the doors freely opened. The doors led to another set of doors that when pushed opened freely to the outside of the facility. The DON called Maintenance Director #13 to come to the East Terrace emergency exit. The Maintenance Director attempted multiple times to lock the doors by putting a code on the keypad located on the wall next to the doors but was unsuccessful. The DON assigned Floor Tech # 8 to guard the emergency exit doors until the door was secure. During an interview conducted on 01/26/2023 at approximately 12:47 PM, the Maintenance Director #13 confirmed he had not performed daily audits on the facility exit doors to ensure they were secure since his employment of about one and half weeks. During an interview conducted on 01/26/2023 at approximately 12:48 PM with the DON and Administrator, the DON stated the last time door audits had been performed were conducted by the previous Maintenance Director. The Administrator stated he would have the door audit logbook located and provided to the surveyor. The door logs were provided to the surveyor and confirmed the last door audit was performed on 12/27/2022. On 01/26/2023 at approximately 1:10 PM the DON advised the surveyors that the emergency exit doors located on the East Terrace had been repaired, were now locked, and the alarm was activated. The DON further stated the wires had been cut inside the panel for the doors that activated the lock and alarm. On 01/26/2023 at approximately 1:35 PM the DON advised the surveyors that the resident had been found on 01/26/2023 at approximately 1:30 PM at the County Mall by the Occupational Therapist #9, who was there to get lunch. Review of the local map of the area revealed the mall was located approximately 1.9 miles from the facility. The Mall's area had heavy traffic areas that included major roadways that had a span of 4 traffic lanes as well as a creek. During an observation on 01/26/2023 at approximately 2:30 PM the DON advised the surveyors that Resident #1's wanderguard was functional at the time of the elopement. The DON then directed Resident #1 to walk to the glass double doors that led to the smokers outside courtyard. The resident walked to the door and attempted to push on the door handle, the door opened, and the audible door alarm was triggered. The double doors opened, and the resident entered through the first set of double doors which triggered an audible wanderguard alarm. The resident diagnosed with dementia, wandering and exit seeking behaviors eloped and had wandered the community for approximately 7 hours before being found. The resident had potential for serious injury, serious harm, or death during that time. The facility provided a plan to remove the immediacy while the surveyors were onsite. An initial plan of removal was submitted to the surveyor team and the Office of Health Care Quality for review on January 26, 2023, at approximately 8:43 PM and was rejected. The 2nd plan of removal was given to the surveyor team and the Office of Health Care Quality for review on January 26, 2023, at approximately 9:34 PM and was rejected. The 3rd plan of removal was given to the surveyor team and the Office of Health Care Quality on January 26, 2023, at approximately 11:07 PM and was rejected. The 4th plan of removal was accepted, and the Immediate Jeopardy was removed on January 27, 2023, at approximately 12:15 AM by the surveyor team and the Office of Health Care Quality. The plan included an audit of all exit doors to ensure the doors are secured and the wanderguard system was functional. The glass double doors that led to the smokers outside courtyard was monitored by an employee throughout each shift until the 15 second fire safety egress was removed by the vendor. The emergency exit door located on the East Terrace Wing was repaired to allow the door to lock and alarm. Mandatory training was conducted for all staff for Elopement and Accident Prevention /Supervision. A process was implemented to identify patterns of residents for elopement risk and accidents to be referred to the Quality Assurance Improvement Plan (QAPI). The plan also included a replacement of the 5-foot wooden fence that enclosed the smokers outside courtyard to a 6 -foot fence. The facility's compliance date for the plan of removal was January 30, 2023. The survey team verified the facility met its date of compliance on January 31, 2023.

Based on record review, observation and interview, it was determined the facility staff failed to allow a competent resident (#6) their right to leave the facility. The facility physically stopped Resident #6 from leaving through the exit door and, as with their previous requests to depart, was told he/she had to wait 4 more days to leave. This failure to allow Resident #6 to leave resulted in actual psychosocial harm that was manifested in a mental state causing him/her to take desperate action on a cold winter night to break a window lock and escape through a ground floor window on foot. This desperate action reflected Resident #6's mental state that they had no other recourse but to break out. This was evident for 1 of 5 residents reviewed for elopement from the facility. The findings include: Review of a compliant (MD 433) received by the Office of Health Care Quality (OHCQ) revealed the following: Resident was at the facility and left the facility through the window on Friday the 12th at 2:00 AM. (He/She) has not been found. This incident was not reported to the OHCQ by the facility. On 1-22-2021 review of the medical record revealed Resident #6, was admitted to the facility on [DATE] from the hospital to complete their quarantine period due to a COVID-19 diagnosis. COVID-19 (Coronavirus Disease 2019), is a disease caused by the coronavirus [DIAGNOSES REDACTED] -CoV-2. COVID-19 spreads from person to person, mainly through respiratory droplets produced when an infected person coughs or sneezes. The 12-1-2020 admission nursing note stated Resident #6 was alert and oriented x3 (alert to person, place, and time) and able to communicate needs but could only express themselves in Spanish Language. All communication with Resident #6 was done through an interpreter. On 12-2-2020 at 1:30 AM per the nursing note, Resident #6 left the COVID unit followed by an unidentified Geriatric Nursing Assistant (GNA), rode the elevator up to the main floor and attempted to exit through the front door. When stopped he/she then became very agitated, went into another room and while trying to exit the building used a half side rail and broke the window where he/she sustained a small cut on his left 4th finger. Resident #6 was redirected to sit down near the dining room because he/she refused to go back downstairs to his/her room. The wound was treated. The on-call physician was notified, who gave the order to transfer Resident #6 back to the hospital as a danger to self and others. A 911 call was made and the County police and emergency medical technicians (EMT) arrived. The police spoke to Resident #6 in Spanish until he/she relaxed and EMT's and police left. The physician canceled the transfer order and Resident #6 went back to his/her room on the COVID Unit. The 12-2-2020 nursing note of 2:47 PM stated Resident #6 was noted in the hallway with jacket insisting he/she wants to leave the facility. Resident #6 was reoriented through the interpreter that he/she is admitted to the facility and is in the COVID unit until his/her [DIAGNOSES REDACTED]. Resident agreed and was redirected to his/her room. The PsychGeriatric note of 12-3-2020 revealed Resident #6 did appear to have a clear knowledge about his/her medical issues or treatment plan. Resident #6 was determined to be oriented to person, place, and date of birth and recognized the Nation's Capital. Resident #6 was determined not to have hallucinations or delusions and diagnosed with [REDACTED]. According to the nursing note of 12-09-2020 Resident #6 was transferred off the COVID unit. On 12-11-2020 Resident #6 was transferred to another room with a roommate. The nursing note of 12-11-2020 at 2:55 PM written by LPN #13 stated Resident walking up and down the hall saying he/she wanted to go home, he/she so try (sic) to go outside I have to run down the hall to try and stop him/her. He/she is back in his/her room sitting on the bed. At this time resident is a candidate for a Wander Guard. Facility investigation into Resident #6's elopement concluded Resident was adamant about going home, however chose not to wait for proper discharge despite his/her brother assuring him/her that he would pick him/her up on Monday. Per psychiatry is oriented, therefore Resident #6 is considered AMA (left against medical advice). Review of GNA # 17's statement written during the facility investigation on the night of 12-11-2020 revealed Resident #6 was staring outside and I asked if he/she was OK and nodded head saying yes. Through an interpreter Resident #6 said he/she had COVID and is better and wants to go home. Around 10:00 PM GNA #17 went to the room and he/she was not there, window was open and the roommate said he/she went out through the window. Interview with Physician on 1-22-2021 at 12:07 PM revealed when the initial assessment was completed on 12-1-2020 resident was standing up and was told he/she had COVID and once cleared would go home and the plan was to keep him/her in isolation until then. Resident was his/her own responsible party and alert without COVID symptoms. He/she did not believe they had COVID. Resident #6 remained in the COVID unit from which he/she was discharged on [DATE] to another room in the facility. Interview on 1-22-2021 at 12:28 PM with Social Worker #6 revealed that Resident #6 had chased him/her out of the room and refused an interpreter and therefore, no care plan meeting had occurred because the social worker assessment was not completed. A discharge plan had also not been completed during the time Resident #6 was at the facility. Social Worker #6 stated on 1-26-2021 that a report was made to Adult Protective Services (APS) on 12-15-2020 but APS did not accept the case due to Resident #6 was deemed competent and alert. Interview on 1-26-2021 at 11:25 AM with LPN #13 revealed the Nursing Supervisor was made aware that Resident #6 wanted to go home but not the Physician and that Resident #6 was not a candidate for a Wander Guard due to being alert and oriented. LPN #13 also stated that this was the first time he/she had worked with Resident #6 and did not know why he/she was here. During interview of Supervisor #14 on 1-26-2021 at 12:29 PM, he/she stated that while on duty on 12-11-2020 he/she was not told that Resident #6 wanted to leave the building. Supervisor #14 was told of the elopement after he/she had left the building at 10:00 PM. This surveyor could not interview Resident #6 due to him/her not having a telephone according to the medical record and brother. On 1-26-2021 at 1:17 PM Resident #6's brother was interviewed via telephone and he said Resident #6 was very upset about being admitted to the facility. Interview with LPN #16 on 1-26-2021 at 2:38 PM revealed that early on the evening shift of 12-11-2020 Resident #6 was angry, going from door to door, and when asked what was wrong said, I want to go home. Resident #6's brother was called who spoke with the Resident and told him/her that he would be picked-up on Monday (this was Friday). LPN #16 did not know why Resident #6 was still there or why he/she could not be picked up at that time. LPN #16 stated he/she did not notify the supervisor or physician that Resident #6 wanted to go home. Resident #6 went back to his/her room. Around 10:30 PM GNA #17 came to LPN #16 and said Resident #6 was not in his/her room. Resident #6's roommate stated he/she had jumped out of the ground floor window and left. Resident #6 had broken the window lock and left through the window. The police were notified and came and searched. The physician was also notified and Resident #6's brother was called multiple times with no answer. Resident #6 who was alert and deemed competent by the nursing staff, social worker, psychiatry, and physician had requested to leave the facility twice on 12-11-2020. Resident #6 was denied the ability to be discharged or discuss discharge with his/her physician. Resident #6 had told the facility staff he/she did not want to be there. A discharge plan had not been made for Resident #6. The physician was never notified of the leave requests on 12-11-2020 nor was the nursing supervisor. Resident #6 was kept in the facility against his/her wishes and had to take a drastic measure of breaking a window lock and leaving through the window at 10:30 PM. The facility failed to honor Resident #6's request for discharge.

Based on resident and staff interviews and review of pertinent documentation it was determined that the facility failed to protect the residents from abuse when staff posted demeaning and abusive comments (in a online forum during August 2016) about Resident #65, when multiple current and former staff were aware of the abusive postings but did not immediately report the concern into facility quality assessment systems, when insufficient actions were taken to protect this resident and all others from similar abuse concerns after administration did become aware on 12/30/16; and when corporate staff deleted the abuse allegations from the corporate reporting system four months after the allegations were received without sufficiently addressing them. This multi-faceted system failure left all residents at increased risk for similar abusive conduct by facility staff. This egregious rights violation resulted in determination by the State Survey Agency (SA) of immediate jeopardy. The facility was notified of the immediate jeopardy at 5:30 PM on 7/6/17. The facility developed a plan sufficient to remove immediacy which was reviewed and accepted at 9:46 PM on 7/6/17. On 7/8/17 at 5:25 PM, surveyors confirmed onsite that the facility implemented its plan to remove immediacy and the immediate jeopardy was abated. After removal of the immediacy, the deficient practice continued with the potential for harm with a scope/severity of F level. The implemented plan to remove immediacy included: - Reporting of the concern to the attending physician for Resident #65 and the Medical Director; - Immediate education of all staff regarding social network communication; and, - Auditing of reported concerns (complaints/grievances) by the facility Administrator and the Regional Director of Operations monthly for 4 months. The findings included: 1. Review of the medical record and interview with Resident #65 revealed that Resident #65 had a [DIAGNOSES REDACTED]. Interview with the Regional Director on 7/6/17 at 3:15 PM and review of an email sent by Resident #65 on 12/30/16, revealed that during August 2016, facility staff #2, #3, and #4 posted commentary online that was identifiable and/or demeaning and abusive to Resident #65, and the resident filed a complaint about the concern on 12/30/16. Facility staff found a photo posting of an unknown person who was morbidly obese that included a caption stating She's having her boyfriend feed her through a funnel so she can become the fattest on earth. Facility staff posted comments to this post indicating We know her competition!!! LOL and It's out secret!!!! LOL. Facility staff posted with the initials of Resident #65's known nick-name that he/she already got us getting documentation together from 3 (years) ago. We think (that he/she) setting us up (for when he/she suffered a named clinical incident 3 years prior). And facility staff posted Girl take (his/her) name off (social media) before we all be sitting in court!!!! On 7/6/17 at 3:15 PM, both the Regional Director of Operations and the Quality Assurance Consultant indicated that the incident posting this commentary had occurred during August 2016. In interview with Resident #65 he/she corroborated, also, that the clinical incident referenced in the online post had occurred 3 years before, consistent with the post. In a verbal statement obtained by the facility on 7/7/16, Resident #65 reported that he/she received notice about the post on 9/12/16. Together, the specific incident named, the timing and location of the specific incident, the initials written in the posted commentary, the identified resident gender, and the clinical condition of [MEDICAL CONDITION] made the posting fully identifiable to Resident #65. In telephone interview on 7/6/17 at 2:47 PM, former employee staff #2 stated that it was absolutely clear that staff #3 and #4 were discussing Resident #65. Staff #2 stated that he/she no longer worked for the facility when the online posting incident occurred but saw the posted conversation and the employee names. Former staff #2 said that he/she then made Resident #65 aware of the online posts. Review of the 12/30/16 email revealed that Resident #65 filed the complaint on 12/30/16 at 2:13 AM, by sending the email to the facility's corporate Care-line (a corporate level internal reporting system for concerns including resident and family concerns). In a verbal statement the facility obtained from Resident #65 on 7/7/17 (after the SA had called the immediate jeopardy), Resident #65 stated that he/she delayed reporting the August 2016 incident because he/she still had to work with the staff and it was important to me that we have a good working relationship despite (the) comments. 2. After receiving the complaint in late December regarding the posting of abusive commentary during August, the facility failed to take sufficient steps to protect all residents in the facility from similar online communications. In interview on 7/6/17 at 11:45 AM, the former Director of Nursing (DON) reported that the former Administrator told staff #3 and #4 to apologize to the resident. Resident #65 reported that the two staff did acknowledge that they had posted the online comments and they apologized. Although the facility staff were instructed to apologize to Resident #65, on 7/6/17 at 3:15 PM, both the Regional Director of Operations and the Quality Assurance Consultant indicated that the photo posted online was not of the resident and the initials noted in facility staff comments did not reflect the resident's legal name, and they did not see or treat the allegations as possible abuse of the resident. The incident therefore was not reported to the State, was not noted in the resident record, was not thoroughly investigated, and system corrective actions were not implemented to protect other residents from similar potential abuse. Corroborating the failure to conduct a thorough investigation as required, in interview on 7/6/16 at 2:33 PM, although GNA staff had apologized, Resident #65 stated that no staff ever spoke to him/her about any investigation or any findings after he/she filed the grievance in writing on the corporate care-line. During an interview with the current Director of Nursing (DON) on 7/6/17 at about 11:00 AM she stated that she did not know about the incident as it occurred prior to her becoming DON. When asked if there was any written investigation, she later stated she was unable to find any. In interview on 7/6/17 at 11:45 AM, the former DON stated that she too was not aware of any investigation that was conducted and she was not aware that any additional education was provided to staff after the incident. 3. Review of the facility policy entitled Standards and Guidelines for Personal Use of Social Media and Social Networking Communication revealed that the facility policy (HR-EM-0051) was last revised during 8/2016. The policy, however, did not prohibit posting abusive commentary about residents in social networking online. The policy did address the importance of staff not posting identifiable information about residents including language that employees must not use social media or personal devices to disclose information about patients or their families. Although requested, no other policies specific to ensuring that staff may not post abusive content online about residents was provided to the survey team. 4. In interview on 7/6/17 at 3:15 PM, the Regional Director of Operations and Quality Assurance Consultant indicated that by policy all reported concerns that are received through the facility care-line are deleted after four months. Review of the medical record revealed that the allegations of the online posting of information, specific to Resident #65, were not found documented in the medical record. Review of the facility grievance log on 7/6/17, revealed that the grievance from the resident about the abuse allegations were, also, not found documented in the grievance log. Thus, without having conducted a thorough investigation and without having sufficiently addressed the allegations of abuse, the allegations were deleted and there was no record of the abuse incident found documented in any identified facility system at the time of the survey. In sum, the facility failed to ensure that effective systems that meet the minimum standards were implemented to protect residents from neglect and abuse. Cross reference Federal Tags F0164, F0166, F0224, F0225, F0226, F0490, F0492, F0493, and F0516; and (NAME)land COMAR Tags 230, 350, 355, 1090, 1855, 1865, 6000, 6022, 6044, 6310, 6322; 6350 and 6352.