Ambassador Healthcare At College Park

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified deficiencies related to the use and maintenance of relocatable power taps (RPTs) and extension cords that did not comply with NFPA 101, NFPA 99, and NFPA 70 requirements. During a facility tour conducted between 11:00 a.m. and 3:30 p.m. with the Maintenance Director, surveyors observed in the social services office an RPT plugged into another RPT, which was then plugged into a wall outlet, with the cord running across a walkway and taped to the floor. In the multipurpose room, a television was found plugged into an extension cord, contrary to standards that prohibit using extension cords as a substitute for fixed wiring and require temporary extensions to be removed immediately after use. Further observations included the MDS office, where an RPT was plugged into another RPT and an outlet adapter was in use. These configurations did not meet the NFPA 99 provisions governing the proper use of power strips and extension cords, including requirements that power strips be appropriately rated and used only as intended, and that extension cords not be used as permanent wiring. During concurrent interviews, the Maintenance Director acknowledged these findings as they were observed by the surveyors.

Plan Of Correction

The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment- Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review. The RPT observed plugged into an RPT plugged into an outlet in the Social Services Office was removed. The extension cord used to plug in the television in the multipurpose room was removed. The RPT plugged into an RPT and outlet adapter in the MDS office was removed. Additional offices and resident care areas will be reviewed for the improper use of plug adapters, power strips and extension. The Executive Director/designee will educate the Maintenance Director on the importance of NFPA 101 Electrical Equipment - Power and Extension specific to the improper use of plug adapters, power strips, and extension and will continue to monitor in accordance with NFPA standards. Any findings will be reported to the monthly QAPI Committee for further review.

Penalty

Inspection fine: $17,675

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment to prevent unsafe wandering and elopement for a cognitively impaired resident. The resident was admitted with diagnoses including esophageal cancer, severe protein‑calorie malnutrition, adult failure to thrive, and a history of immunosuppression therapy. Therapy and clinical evaluations shortly after admission documented moderate cognitive impairment, decreased insight, poor judgment, and decreased safety awareness. A Speech Language Pathology evaluation showed moderate cognitive‑communication deficits with impaired short‑term memory, problem solving, and executive functioning, and a SLUMS score indicating moderate cognitive impairment. The admission MDS BIMS score also indicated moderate cognitive impairment, and the care plan identified cognitive loss/dementia and fall risk. Multiple nursing and provider notes over the following weeks documented intermittent and worsening confusion, treatment‑interfering behaviors such as repeatedly pulling out IV/PICC lines, disorientation, and statements reflecting confusion. Despite this documentation, the facility’s Elopement Risk Evaluation completed on 11/6/25 concluded the resident was not at risk for elopement. The Unit Manager who completed the tool answered “No” to questions about cognitive impairment, poor decision‑making, exit‑seeking behaviors, wandering oblivious to safety, and history of elopement, while acknowledging the resident was independently mobile and able to exit the facility. On 11/19/25, a psychiatric APRN formally evaluated the resident for capacity at the request of the primary physician and documented that the resident lacked capacity to make decisions related to healthcare or long‑term placement, was significantly disoriented, and could benefit from a guardian or POA. Another APRN note the same day described significant disorientation and fluctuating mental status, with risk of delirium and unsafe behaviors. Nonetheless, the facility did not update the elopement risk assessment or care plan to reflect this change in condition and did not implement elopement‑specific interventions. On the day of the incident, staff notes and the facility’s own timeline show that the resident was last seen at the nursing station around mid‑morning, when he denied needing anything. The front desk receptionist left the front desk unattended to go to the kitchen, and the front door, which could be opened without staff intervention, was left accessible. Around that time, EMS exited the building with another resident, and the facility asserts the doors closed and locked, but the receptionist later stated that a visitor likely opened the front door, allowing the cognitively impaired resident to leave unnoticed. The resident walked out the front door, crossed a two‑lane road, and traveled approximately half a mile over uneven terrain and near multiple water retention ponds to a nearby college dormitory. College staff found him in the dorm, describing him as confused, disoriented, unsteady, shaking, disheveled, and unsure of where he was. EMS documentation noted he did not remember where he was supposed to be and believed he was in a different city. The facility did not become aware that the resident had left until contacted by campus security after EMS had been called, and there was no documentation in the clinical record that the resident had exited the facility without staff knowledge or supervision. Interviews with the Unit Manager indicated she was told not to document the incident and that no elopement re‑evaluation or care plan update was completed afterward. The facility’s failure to recognize and act on the resident’s documented cognitive impairment and lack of capacity, to accurately assess elopement risk, to maintain supervision at the front entrance, and to document the elopement led to the determination of Immediate Jeopardy under F689. The resident’s family member reported being very upset that they were not notified of the incident until 24 hours later and expressed concern about what could have happened while the resident was unsupervised outside the facility. The Administrator and DON acknowledged in interviews that the resident left the facility without staff knowledge and supervision, but the Administrator repeatedly resisted characterizing the event as an elopement, instead describing it as the resident going for a walk and forgetting to sign out. The Administrator also stated that she would allow residents she considered cognitively impaired but without a formal incapacity statement to leave unsupervised and was unaware of the psychiatric APRN’s documented incapacity determination at the time. The DON confirmed that she did not direct staff to make a late entry documenting the incident and did not order a new elopement risk assessment, stating she believed the resident was alert and oriented and that a new evaluation was only done when a resident newly expressed a desire to leave and “did not make sense.” These actions and inactions, in the context of extensive documentation of confusion and impaired safety awareness, contributed directly to the unsafe elopement and the cited deficiency for failure to prevent accidents and provide adequate supervision.

Removal Plan

• Resident #900 no longer resides at the facility and was successfully discharged home as planned.
• Resident #900 was immediately placed on 1:1 staff observation.
• A licensed nurse performed a complete skin inspection for Resident #900 with no new skin concerns identified.
• Resident #900’s cognitive status was re-evaluated using the BIMS assessment.
• The Administrator/Designee re-educated all staff on Missing Resident Drill and Elopement policy, emphasizing responding to door alarms, using the elopement binder, performing a resident headcount, and Administrator/DON notification.
• The Administrator modified the receptionist process for residents exiting the facility and added it to new hire education, including use of a binder with blue (requires supervision) and white (safe for unsupervised LOA) sheets, clinical team determination of supervision, and resident sign-in/sign-out for each LOA; front door opened by remote or keypad.
• The contracted vendor removed the automatic open option on the front double doors so doors remain locked with access by staff remote or keypad entry/exit only.
• The facility extended receptionist hours to 7:00 a.m.–9:00 p.m., 7 days/week.
• The front desk coverage process was updated to establish coverage when the receptionist is on break/steps away and to define the process for 9:00 p.m.–7:00 a.m. for assisting residents with LOA and/or visitors entering/exiting.
• Residents admitted in the last 30 days were re-evaluated for accuracy of new admission assessments and documentation related to cognitive status and elopement risk by the DON/Designee.
• The Administrator confirmed the LOA process is included in the new admission packet.
• The DON/Designee completed a new elopement risk assessment on all current residents in the electronic medical record system.
• The receptionist on duty for the event was re-educated on ensuring residents exiting the facility were approved by clinical staff prior to exit and on the binder/blue-white sheet LOA process and door access process.
• The DON/Designee re-educated all employees on F689 (including CMS definition of elopement), the updated facility elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident exiting (binder/blue-white sheets, clinical team determination, sign-in/sign-out, remote/keypad door access).
• All licensed nurses were educated on communicating physician changes to a resident’s capacity and notifying the DON and/or Administrator at the time of determination to ensure timely re-evaluation of elopement risk.
• An ad hoc QA meeting was held with the facility Medical Director in attendance via phone.

Penalty

Inspection fine: $17,675

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility administration failed to provide effective oversight and implement processes to ensure resident safety related to unsafe wandering and elopement. A cognitively impaired, ambulatory, and confused resident with poor safety awareness exited the building through an unlocked front door after walking past an unattended front desk. The resident crossed a two-lane road and walked approximately half a mile over uneven terrain and near water ponds to a nearby college dormitory. Facility staff were unaware the resident had left until they were notified by college campus security about the resident’s transfer to a local emergency room via EMS. The resident had multiple documented indicators of cognitive impairment and safety risk prior to the incident. The admission MDS showed moderately impaired cognition with a BIMS score of 12 and a need for partial to moderate assistance with ambulation and activities of daily living. Speech therapy documented moderate cognitive-communication deficits with problems in short-term memory, problem solving, and executive functioning. Nursing and provider notes described intermittent confusion, pulling out IV lines, statements indicating disorientation, and treatment-interfering behaviors requiring close supervision and safety monitoring. A psychiatric APRN documented that the resident lacked capacity to make healthcare and long-term placement decisions, was unable to understand the consequences of not receiving care, and recommended a guardian or POA. Despite this, the admission elopement assessment scored the resident as not at risk for elopement, there were no subsequent elopement reassessments, and the care plan, while noting impaired cognition, did not translate into effective elopement risk management. After the resident left the facility unsupervised, the administration did not consider the event an elopement and did not document the incident or any measures to prevent further unsafe wandering in the clinical record. The Administrator characterized the event as the resident going out for a walk and failing to sign out, and stated the resident was cognitively intact based on a BIMS score obtained upon return, despite prior documentation of incapacity and dementia-level SLUMS scoring. The DON expressed a desire not to label the event as an elopement and acknowledged there was no documentation in the record about the incident, stating she did not want to enter a late note because the Administrator conducted the investigation. A Unit Manager LPN reported being told not to document anything and that the Administrator and DON would handle it. The facility had an elopement prevention policy defining elopement for incapacitated residents and requiring an elopement risk assessment, monitoring device, and care plan when such a resident wanders into an unsafe area or leaves the building, but these processes were not implemented for this resident. The lack of adequate supervision, failure to recognize and classify the event as an elopement, failure to reassess elopement risk, and failure to document the incident and related interventions led to a determination of Immediate Jeopardy under F835.

Removal Plan

• Resident #900 was successfully discharged home as planned.
• The Administrator/Designee completed staff re-education on Missing Resident Drill and Elopement with all staff members, emphasizing responding to door alarms, using the elopement binder, performing a resident headcount, and Administrator and DON notification.
• The Administrator/Designee completed Missing Resident Drills at varying times with staff members participating collectively from each department.
• The Administrator modified the receptionist process for residents exiting the facility and added this to education for newly hired staff, including use of a newly created binder with blue (supervision required) or white (safe for unsupervised LOA) sheets for each resident, requiring residents to sign in/out for LOA each time they leave, and opening the front door by remote or keypad.
• The facility’s contracted vendor removed the automatic open option on the front double doors so doors remain locked with access by staff remote or keypad entry/exit only.
• The facility extended receptionist hours and updated the front desk coverage process for breaks/step-away coverage and for after-hours coverage for LOA/visitors.
• The Chief Nursing Officer re-educated the Administrator and Director of Nursing on the CMS definition of elopement, their roles to ensure resident safety, and the expectation to complete a risk management report for elopement events.
• The facility changed its elopement policy to reflect CMS’s definition of elopement.
• The interdisciplinary team was re-educated on reporting and documenting resident incidents in the clinical record, the alleged deficient practice outlined on the immediate jeopardy template, and federal regulation F835, emphasizing adherence to medical record documentation policies and procedures.
• Residents admitted in the last 30 days were re-evaluated for accuracy of new admission assessments and documentation related to cognitive status and elopement risk.
• The receptionist on duty for the event was re-educated on ensuring residents exiting the facility were approved by clinical staff prior to allowing exit and on use of the LOA binder/blue-white sheets, sign in/out requirement, and door access by remote/keypad.
• The Director of Nursing/Designee completed new elopement risk assessments on all current residents in the EMR.
• All licensed nurses were educated on communicating physician determinations/changes in resident capacity to notify the DON and/or Administrator timely to ensure prompt re-evaluation of elopement risk.
• Staff were re-educated on the CMS definition of elopement, the updated elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident exits (including binder/blue-white sheets, clinical team determination of supervision for LOAs, sign in/out requirement, and door access by remote/keypad).
• An ADHOC QAPI meeting was held with the medical director participating by phone, and the QAPI committee approved the recommendations.
• QA meetings included review of the new receptionist process for residents exiting the facility.

Penalty

Inspection fine: $17,675

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who eloped from the facility and was sent to the emergency room. Facility policy required that nurse’s notes be written by licensed/qualified nursing personnel, address the resident’s condition, be specific and objective, and be signed with the writer’s name and credentials, with frequency of entries based on resident need and changes in condition. The resident was admitted in early November and had an admission MDS showing a BIMS score of 12, indicating moderately impaired cognition. Nursing progress notes documented the resident’s level of consciousness and orientation on the evening of one date, with the next note two days later, but there was no documentation in the clinical record of the resident’s elopement, emergency room visit, or return to the facility. Interviews and external records confirmed that on a late November morning the resident exited the facility without staff knowledge or supervision, walked to a nearby state college dormitory, and was found there confused, disoriented, unsteady, and shaking. Campus personnel contacted EMS, which transported the resident to a local emergency room, with EMS records documenting times of response, departure, and transfer. The DON and Administrator verified the elopement and lack of documentation in the clinical record, and a unit manager stated she had been told not to document anything about the incident in the record, believing the DON and Administrator would handle it. The Administrator reported that a BIMS test was administered upon the resident’s return, but the provided BIMS form was unsigned and lacked the writer’s credentials, further contributing to the incomplete and noncompliant documentation of the resident’s medical record.

Penalty

Inspection fine: $78,430

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to follow the care plan and safety precautions for a resident with Alzheimer's Disease, anxiety disorder, and major depressive disorder, who had severely impaired cognition and was dependent on staff for activities of daily living (ADLs). The resident required substantial or maximum assistance of two staff members for bed mobility, as documented in both the care plan and the electronic Kardex system. Despite these requirements, a Certified Nursing Assistant (CNA) provided care alone, rolled the resident toward her, and the resident fell out of bed, sustaining a forehead injury that required hospital transfer and sutures. Interviews revealed that the CNA was unaware of the two-person assist requirement and had not been trained on the Kardex system during orientation. The CNA reported having provided solo care to the resident multiple times previously. The Director of Nursing (DON) and Licensed Nursing Home Administrator (LNHA) confirmed that the CNA did not follow the resident's plan of care, and both identified this as neglect. The facility's investigation substantiated that the failure to follow the care plan and lack of staff training directly led to the resident's fall and injury.

Penalty

Inspection fine: $78,430

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with Alzheimer's Disease, severe cognitive impairment, and significant ADL self-care deficits experienced a fall with injury during care. The resident's care plan and Kardex specified the need for substantial or maximum assistance of two staff members for bed mobility due to weakness and impaired balance. However, a CNA provided care alone, rolled the resident toward herself, and the resident fell out of bed, sustaining a forehead laceration that required hospital transfer and sutures. Staff interviews revealed that the CNA was unaware of the resident's two-person assist requirement and had not received training on the Kardex system during orientation. The DON and LNHA confirmed that the CNA did not follow the resident's plan of care, and the incident was substantiated as neglect. The facility's policy required that residents unable to perform ADLs independently receive necessary services, but this was not followed in this case, resulting in an avoidable accident and injury.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely assistance with dining for two residents who required help with their meals. Resident #2, diagnosed with Parkinson's Disease, was observed lying in bed with a breakfast tray placed out of reach on an over-the-bed table. The resident required partial to moderate assistance with eating, but the tray was not set up, and the resident was not awakened to eat. Similarly, Resident #3, who had a diagnosis of malignant neoplasm, was also observed with a breakfast tray out of reach. This resident required setup or cleanup assistance with eating, but the tray was left on the table without being set up, and the resident was not positioned to eat. Interviews with staff revealed that the Certified Nursing Assistant (CNA) responsible for delivering meal trays left them out of reach until all trays were delivered, delaying assistance for residents needing help. The Registered Nurse (RN) and Unit Manager confirmed that residents requiring assistance should have their trays delivered last and set up immediately. However, this protocol was not followed, leading to the deficiency. The Director of Nursing and Regional Nurse Consultant reiterated that trays should not be left without setting up and waking the resident, as outlined in the facility's care instructions.