Crenshaw Nursing Home, DAB CR6809 (2026)

DECISION

Crenshaw Nursing Home (Petitioner or “the facility”) is a long-term care facility that participates in the Medicare program.  Based on surveys that were completed on May 3 and June 10, 2022, the Centers for Medicare & Medicaid Services (CMS) determined that Petitioner was not in substantial compliance with Medicare participation requirements and imposed against Petitioner a per-instance civil money penalty (CMP) of $12,605.  For the reasons discussed below, I find that Petitioner was not in substantial compliance with Medicare program requirements and the remedy imposed is reasonable.  

I. Background

The Social Security Act (Act) sets requirements for skilled nursing facility (SNF) participation in the Medicare program.  The Act authorizes the Secretary of the United States Department of Health & Human Services (Secretary) to promulgate regulations implementing those statutory provisions.  Act § 1819 (42 U.S.C. § 1395i-3).  The Secretary’s regulations are found at 42 C.F.R. part 483. 

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A facility must maintain substantial compliance with program requirements in order to participate in the program.  To be in substantial compliance, a facility’s deficiencies may pose no greater risk to resident health and safety than “the potential for causing minimal harm.”  42 C.F.R. § 488.301. 

The Secretary contracts with state agencies to conduct periodic surveys to determine whether SNFs are in substantial compliance with the participation requirements.  Act § 1864(a) (42 U.S.C. § 1395aa(a)); 42 C.F.R. §§ 488.10, 488.20.  The Act and its implementing regulations require that facilities be surveyed on average every 12 months, and more often if necessary, to ensure that identified deficiencies are corrected.  Act § 1819(g)(2)(A) (42 U.S.C. § 1395i-3(g)(2)(A)); 42 C.F.R. §§ 488.20(a), 488.308. 

On May 3, 2022, surveyors from the California Department of Public Health (state agency or CDPH) completed a survey to investigate an entity-reported incident.  CMS Exhibit (Ex.) 49.  As a result of that survey, the state agency found that the facility was not in substantial compliance with Medicare participation requirements and that the cited deficiency constituted immediate jeopardy to resident health and safety.1  CMS Ex. 45 at 10-19.  The state agency determined that the facility was not in substantial compliance with the participation requirement that it ensure that the resident environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents (Tag F6892) (42 C.F.R. 

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§ 483.25(d) (cited at the “J” level of scope and severity)).3  CMS Ex. 37; CMS Ex. 49.  By letter dated August 1, 2022, CMS informed Petitioner that the cited deficiency posed immediate jeopardy on May 2, 2022, and that the noncompliance constituted “substandard quality of care.”4  CMS Ex. 49.  CMS imposed a per-instance CMP in the amount of $12,605.  Id. at 2.  

On September 30, 2022, Petitioner requested an administrative law judge (ALJ) hearing.  Pursuant to the Acknowledgment and Standing Order (Standing Order), CMS submitted a pre-hearing brief (CMS Br.) incorporating a motion for summary judgment, along with 50 exhibits (CMS Exs. 1-50).  Petitioner filed an opposition to CMS’s motion for summary judgment and a pre-hearing brief (P. Br.), and also submitted nine exhibits (P. Exs. 1-9).  Both parties filed supplement briefing to include CMS exhibits 51-52 and Petitioner’s exhibits 10-16.  The parties objected to each other’s proposed exhibits.  At a prehearing conference held on August 9, 2024, ALJ Tannisha Bell5 overruled the parties’ objections and admitted the exhibits into evidence pending authentication of any sworn witness statements subject to cross-examination at hearing. 

The parties also both submitted written direct testimony pursuant to the Standing Order.  Requests for cross-examination were made, and a hearing was scheduled for October 22, 2024.  However, on October 10, 2024, the parties filed a stipulation to have the case decided on the written record.  42 C.F.R. § 498.66.  The parties were given the chance to submit closing arguments, which were filed on December 6, 2024 (CMS Closing Br.; P. Closing Br.).  As a result, this case is now ripe for decision and the remaining exhibits not previously admitted into the record are now admitted. 

II. Issues

The following issues will be addressed in this decision: 

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• 1) Whether Petitioner failed to be in substantial compliance with the Medicare program participation requirement at 42 C.F.R. § 483.25(d)(1)-(2).  
• 2) If Petitioner was not in substantial compliance with 42 C.F.R. § 483.25(d)(1)-(2), whether the finding of immediate jeopardy is subject to review.  
• 3) If Petitioner was not in substantial compliance with 42 C.F.R. § 483.25(d)(1)-(2), whether the imposed enforcement remedy, a $12,605 per-instance CMP, is reasonable.   

III.  Findings of Fact and Conclusions of Law

1. A. Background

Petitioner is a SNF located in Los Angeles, California.  CMS Ex. 49 at 1.  The facility is located in a part of Los Angeles that has a high crime rate.  CMS Ex. 45 at 4; CMS Ex. 50 at 5 (Hoffman Decl. ¶ 10).  The facility itself shares a common wall with Westside Manor, an assisted living facility.  CMS Ex. 50 at 5 (Hoffman Decl. ¶ 12).  There is a door between Petitioner’s facility and the assisted living facility.  Id.  The door did not have an alarm but could only be opened from the assisted living facility side.  Id.  To access the door between the two facilities, Petitioner’s residents would need to access the back patio.  Id.  The door between the facility and the back patio did have an alarm, but since the door was open and broken, the alarm did not sound upon opening.  Id. 

Resident 1 was admitted to the facility on December 30, 2021 and re-admitted to the facility on April 13, 2022, with diagnoses that included schizoaffective disorder, schizophrenia, psychosis, and psychoactive substance dependence.  CMS Ex. 35 at 1-2, 120; CMS Ex. 45 at 14.  Petitioner identified Resident 1 as being unable to process internal stimuli, which would cause anger that leads to self-harm or harm to others.  CMS Ex. 35 at 112.  Resident 1’s January 31, 2022 minimum data set (MDS) indicated she had the ability to understand and be understood but required supervision with locomotion on unit and locomotion off unit.  CMS Ex. 35 at 23-28; CMS Ex. 45 at 15.  Resident 1’s March 18, 2022 elopement risk evaluation indicated that she was at risk for elopement.  CMS Ex. 35 at 119-120; CMS Ex. 45 at 15.  Resident 1 also apparently told the facility on multiple occasions that she wished to leave.  CMS Ex. 45 at 15; CMS Ex. 50. 

Resident 1’s March 18, 2022 elopement risk care plan included monitoring Resident 1 at frequent intervals, redirecting the resident, providing one-on-one supervision as necessary, administering required medications, and an interdisciplinary team meeting to address the elopement risk.  CMS Ex. 35 at 119-120.  Resident 1’s January 25, 2022 fall risk care plan called for her to be put close to the nursing station for frequent observation and for her to have frequent visual monitoring.  CMS Ex. 35 at 117. 

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On April 25, 2022, Licensed Vocational Nurse (LVN) Ukemba worked from approximately 3:00 p.m. to 11:00 p.m.  CMS Ex. 26 at 6.  He provided a written statement on April 26, 2022, detailing his encounter with Resident 1 on April 25, 2022.  CMS Ex. 26.  LVN Ukemba stated that at 9:20 p.m. on April 25, 2022, he saw Resident 1 go through a gate into the assisted living facility with a male resident.  CMS Ex. 26 at 6.  LVN Ukemba had a conversation with Resident 1 who stated that she wanted to stay in the assisted living facility.  Id.  LVN Ukemba explained that she was not allowed there and escorted her back to Petitioner’s facility.  Id.  LVN Ukemba did not indicate that he told anyone about the incident, and it does not appear from the records provided that he made any contemporaneous reports about the incident. 

On April 25, 2022, at approximately 9:28 p.m., Resident 1 left the facility by accessing the back patio and gaining access to the assisted living facility when a resident opened the door for her.  CMS Ex. 50 at 4; CMS Ex. 5 at 2.  Resident 1 was then able to leave the assisted living facility through its front door.  CMS Ex. 50.  A photograph was provided showing Resident outside the assisted living facility at 9:39 p.m.  CMS Ex. 1 at 10. 

On the morning of April 26, 2022, Petitioner’s Administrator discovered that Resident 1 was not at the facility.  CMS Ex. 5 at 2.  It was not until 9:30 a.m. on April 26, 2022, that Petitioner called CDPH to report that Resident 1 had eloped.  CMS Ex. 33 at 1.  At that same time, the administrator called the facility lockdown code.  CMS Ex. 5 at 2. 

A review of the security footage from April 25, 2022, shows a certified nursing assistant (CNA) encounter Resident 1 on the back patio of the facility, but the CNA did nothing to stop Resident 1 from leaving.  CMS Ex. 50 at 4; CMS Ex. 27. 

Resident 1 returned to the facility on April 28, 2022, at approximately 2:45 p.m.  CMS Ex. 45 at 11.  On April 29, 2022, she was admitted to a local hospital.  CMS Ex. 46.  Resident 1 communicated to the hospital staff that she had consumed three bottles of alcohol in the past two days, and hospital records showed that based on a urine sample collected on April 28, 2022, Resident 1 tested positive for amphetamines and cocaine.  CMS Ex. 46 at 7. 

The surveyor ultimately concluded that Petitioner failed to properly supervise Resident 1, failed to ensure that Resident 1’s elopement risk interventions were in place, failed to ensure that access to the assisted living facility was closed, failed to complete an elopement risk assessment when Resident 1 was re-admitted on April 13, 2022, and failed to ensure staff activated a code green lockdown.  CMS Ex. 45 at 10-11. 

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1. B. Analysis

• Petitioner was not in substantial compliance with 42 C.F.R. § 483.25(d) because it did not take all reasonable steps to ensure that a resident with a foreseeable risk of elopement was given adequate supervision and assistance devices to prevent elopement from the facility.  

Pursuant to 42 C.F.R. § 483.25(d), a facility has specific obligations related to accident hazards and accidents.  That provision states, in relevant part:  

• (d) Accidents.  The facility must ensure that –
  • (1) The resident environment remains as free of accident hazards as is possible; and
  • (2) Each resident receives adequate supervision and assistance devices to prevent accidents.   

42 C.F.R. § 483.25(d).  

The Departmental Appeals Board (DAB) has explained that the stated goal of 42 C.F.R. § 483.25(d)6 is “to prevent ‘accidents’ that might harm a SNF resident.”  Crawford Healthcare & Rehab., DAB No. 2738 at 5 (2016).  A facility must “take all reasonable steps to ensure that a resident receives supervision and assistance devices that meet his or her assessed needs and mitigate foreseeable risks of harm from accidents.”  Briarwood Nursing Ctr., DAB No. 2115 at 5 (2007); Guardian Health Care Ctr., DAB No. 1943 at 18 (2004).  The facility must anticipate what accidents might befall a resident and take steps to prevent them.  “A facility is permitted the flexibility to choose the methods it uses to prevent accidents, but the chosen methods must constitute an ‘adequate’ level of supervision under all the circumstances.”  Windsor Health Care Ctr., DAB No. 1902 at 5 (2003).  A facility must address foreseeable risks of harm from accidents “by identifying and removing hazards, where possible, or where the hazard is unavoidable because of other resident needs, managing the hazard by reducing the risk of accident to the extent possible.”  Maine Veterans’ Home - Scarborough, DAB No. 1975 at 10 (2005) (explaining the inherent standard of care in section 483.25(d)(1)).  The provisions of section 483.25(d) “come into play when there are conditions in a facility that pose a 

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known or foreseeable risk of accidental harm.”  Meridian Nursing Ctr., DAB No. 2265 at 10 (2009), aff’d sub nom. Fal-Meridian, Inc. v. U.S. Dep’t of Health & Hum. Servs., 604 F.3d 445 (7th Cir. 2010). 

On April 25, 2022, Resident 1 was able to leave the facility and was not reported missing until the next day – approximately 12 hours later.  CMS Ex. 5 at 2.  Resident 1’s care plan included interventions for monitoring her at frequent intervals, a team conference, medication administration, redirection, and one-on-one supervision, as required.  CMS Ex. 35 at 119-120.  Resident 1’s fall risk plan required frequent visual monitoring and placement close to the nursing station for observation.  Id. at 117.  The facility had a log in place for Resident 1 where staff was supposed to monitor and document her location every hour.  CMS Ex. 35 at 107-108.  However, the monitoring log had no entries from 3:00 p.m. to 11:00 p.m. on April 25, 2022, or at 12:00 a.m. on April 26, 2022.  CMS Ex. 35 at 108; CMS Ex. 45 at 16.  On April 25, 2022, Resident 1’s medications included antipsychotics and mood stabilizers.  CMS Ex. 45 at 16.  The record reflects that Resident 1 did not have her medications when she left the facility.  CMS Ex. 50; CMS Ex. 35 at 75-78.  The Director of Nursing (DON) indicated that not taking her medications could lead to a decline in Resident 1’s health.  CMS Ex. 45 at 16. 

Additionally, the MDS nurse informed the surveyor that no IDT meeting for risk of elopement was ever held for Resident 1 pursuant to her care plan.  CMS Ex. 45 at 17, 18.  Nurses who were assigned to care for Resident 1 informed the surveyor that they did not know that a care plan or elopement risk plan was in place for Resident 1.  Id. 

As noted above, Resident 1 left the facility on April 25, 2022, at approximately 9:30 p.m.  CMS Ex. 50 at 4.  Resident 1 was able to leave the facility through the front entrance of the assisted living facility next door.  Id.  Resident 1 accomplished this by accessing a back patio that belonged to Petitioner’s facility and gaining access to the assisted living facility when another patient opened the door.  Id.  During this time, no alarms were sounded and no reports were made, despite one of Petitioner’s nurses7 seeing Resident 1 on the patio.  CMS Ex. 50 at 4-5.  When the surveyor visited the facility, the door between Petitioner’s facility and the skilled nursing facility did not have an alarm.  CMS Ex. 50 at 5.  The door between the facility and the back patio did have an alarm, but since the door was open and broken, the alarm did not sound upon opening.  Id. 

It was not until April 26, 2022, at approximately 9:39 a.m., that the social services director called the CDPH and the police to report that Resident 1 had eloped.  CMS Ex. 35 at 140.  The notes reflect that Resident 1’s daughter was called on April 26, 2022, at 1:43 p.m.  Id. 

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During the course of her investigation, the surveyor spoke with multiple nurses who indicated that they were unaware that Resident 1 was missing during their shifts that evening of April 25, 2022 and morning of April 26, 2022.  CMS Ex. 26 at 2; CMS Ex 50.  The CNA assigned to Resident 1 on April 25, 2022, told the DON that she brought Resident 1 her dinner in her room, but she did not see her the rest of her shift.  CMS Ex. 26 at 4-5.  Two of the nurses were fired following this incident.  Id.; CMS Ex. 29 at 1. 

The surveyor and the DON spoke with the charge nurse on duty on April 25, 2022 during the 11:00 p.m. to 7:00 a.m. shift.  CMS Ex. 50 at 10.  The charge nurse explained that when someone elopes, the process is to inform the DON and the administrator.  Id.  However, she explained that they would not call the police if the resident was considered self-responsible.  Id.  The charge nurse said that she noticed Resident 1 was not in her bed around 11:00 p.m., looked around the facility for her, and asked her roommate and another nurse if they had seen her, but she ultimately took no action because Resident 1’s chart said she was self-responsible.  Id.  The charge nurse also told the DON and the surveyor that she did not know that Resident 1 was at risk for elopement.  Id.  The charge nurse was given a two-day suspension for failing to report a missing resident, failing to document the incident of a missing resident, and failing to monitor the missing resident.  CMS Ex. 25. 

The nurses told the surveyor that if a resident goes missing, the staff is supposed to initiate the lockdown procedure.  CMS Ex. 50 at 14.  This procedure includes calling a code green lockdown, searching the facility for the resident, preventing anyone from coming and going, calling the police, notifying the DON and administration as well as the doctor and the police, and calling the resident’s physician and CDPH.  CMS Ex. 50 at 7.  Resident 1 left the facility around 9:30 p.m. on April 25, 2022, but a code green lockdown was not called until 9:30 a.m. on April 26, 2022.  CMS Ex. 13.  A nurse told the surveyor that a code green lockdown should have been called as soon as someone noticed that Resident 1 was missing.  CMS Ex. 50.  However, other nurses at the facility were unaware of the process for a missing resident.  Id. at 9-10, 14. 

Resident 1 returned to the facility on her own on April 28, 2022 and was subsequently admitted to a local hospital.  CMS Ex. 46.  The record indicates that during her time away from the facility, Resident 1 drank alcohol, and took some amphetamines and cocaine.  Id.  The diagnoses at the time of her hospital admittance included psychosis with delusions, cocaine abuse, and alcohol abuse.  CMS Ex. 46 at 81.  The hospital records indicate that Resident 1 also had suicidal ideations and an intention to overdose.  Id. at 61. 

Petitioner argues that Resident 1 signed a form to leave the facility against medical advice (AMA) and that the execution of said form absolves them of all liability.  P. Br. at 4-5 (citing P. Ex. 4).  However, as previously discussed, the actions taken by the facility 

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upon realizing that Resident 1 was missing do not support the conclusion that Resident 1 signed an AMA form and left with permission of the facility.  Petitioner fired multiple nurses following their investigation into Resident 1’s elopement.  The facility alerted the police, the CDPH, her family and her doctors that Resident 1 was missing and made no mention of an AMA form.  In fact, Petitioner continued to search for Resident 1 until she reappeared at the facility on her own on April 28, 2022.  There is no mention of an AMA made during this time.  There is no mention of an AMA form until May 10, 2022.  And, the only evidence to support that an AMA form was in place at the time Resident 1 went missing is the sworn statement from Mr. Elliott, a former admissions coordinator at Petitioner’s facility.  P. Ex. 12.  This sworn statement is in direct contradiction to the remainder of the evidence in this case.  See, e.g., CMS Ex. 36 at 35 (Hospital records indicate that Resident 1 suddenly “went out of the nursing home without signing AMA . . . .”).  As a result, I do not find that the evidence supports that Resident 1 had a proper AMA in place on April 25, 2022, when she left Petitioner’s facility. 

Additionally, Petitioner’s actions violated its own AMA policy.  CMS Ex. 10 at 34.  If an AMA was in place, Petitioner should have documented “a specific notation on the patient’s medical record regarding the AMA and circumstances surrounding the AMA.”  CMS Closing Br. at 4-6. 

I need only determine whether Petitioner substantially complied with 42 C.F.R. § 483.25(d), which means that I must determine whether Petitioner ensured that the resident environment was as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents.  42 C.F.R. § 483.25(d).  It is clear from the record provided that Petitioner did not provide adequate supervision of Resident 1 to prevent her from eloping.  Most specifically, Petitioner’s staff did not follow the care plan it put in place.  The nurses did not provide frequent monitoring of Resident 1, and they did not document her whereabouts.  It took almost 12 hours before any authorities were called and a report of her missing was made.  Petitioner failed to have the supervision and assistance devices (i.e., monitored alarms, motion sensors, cameras, wearable alarm devices) that could have prevented the elopement or notified Petitioner of the elopement.  Resident 1 was a known elopement risk, and Petitioner failed to provide adequate supervision when she walked out to the facility’s back patio and through the front door of assisted living facility next door.  There is a sufficient basis to find noncompliance with 42 C.F.R. § 483.25(d).  Resident 1 eloped and was not located for nearly 72 hours, and Petitioner did not substantially comply with 42 C.F.R. § 483.25(d). 

CMS also discusses an alleged elopement with regard to Resident 4, which Petitioner objects to on grounds that it wasn’t included in the surveyor’s reports and that Resident 4 also had an AMA form in place.  I find that the evidence submitted likely supports the contentions made by CMS, but it is not necessary to analyze them here.  I agree that Resident 4 was not included in the statement of deficiencies, was not a basis originally 

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cited for the immediate jeopardy determination, and his elopement is not necessary to support the $12,605 CMP. 

• The immediate jeopardy determination is not subject to review because the amount of the per-instance CMP is not affected by a determination of whether there is immediate jeopardy. 

CMS concluded that Petitioner’s noncompliance with 42 C.F.R. § 483.25(d) posed immediate jeopardy at the “J” scope and severity level.  Petitioner argues that an immediate jeopardy determination is erroneous.  P. Br. at 13-14.  However, because CMS imposed a per-instance CMP for this deficiency, I lack authority to review CMS’s immediate jeopardy determination. 

The regulations are clear that an ALJ may review CMS’s scope and severity findings (which includes a finding of immediate jeopardy) only if a successful challenge would affect:  (1) the range of the CMP amounts that CMS could collect; or (2) a finding of substandard quality of care that results in the loss of approval of a facility’s nurse aide training program (NATCEP).  42 C.F.R. § 498.3(b)(14), (d)(10)(i)-(ii); NMS Healthcare of Hagerstown, DAB No. 2603 at 6-7 (2014).  Neither of these factors apply. 

Unlike per-day CMPs, under the regulations, there is only a single monetary range for a per-instance CMP regardless of whether or not immediate jeopardy is present.  42 C.F.R. §§ 488.408, 488.438(a)(2).  Consequently, because CMS only imposed a per-instance CMP against Petitioner, a successful challenge to the immediate jeopardy finding would not affect the range of CMP amounts that CMS could collect.  NMS Healthcare of Hagerstown, DAB No. 2603 at 6-7.  Further, the evidence does not indicate that Petitioner had a NATCEP, nor does Petitioner argue that it had one.  Even if Petitioner had a NATCEP and lost the approval of the NATCEP due to the finding of substandard quality of care, CMS Ex. 49 at 1, “the loss of approval for a NATCEP program would not be affected by a successful challenge to the level of noncompliance because, by operation of law, the imposition of a CMP of [$11,995] or more results in NATCEP loss whether or not immediate jeopardy is present.”  Fort Madison Health Ctr., DAB No. 2403 at 13 (2011) (citing Act § 1819(f)(2)(B)(iii)(I)); 45 C.F.R. § 102.3 (2022) (adjusting $5,000 for inflation, which amounts to $11,995).  In this case, as explained below, I found the $12,605 to be reasonable and upheld it.  For these reasons, the immediate jeopardy finding is not subject to appeal, and I may not review it. 

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• A per-instance CMP of $12,605 is a reasonable enforcement remedy for Petitioner’s noncompliance with 42 C.F.R. § 483.25(d). 

If a facility is not in substantial compliance with program requirements, CMS has the authority to impose one or more of the enforcement remedies listed in 42 C.F.R. § 488.406, including a CMP.  In determining whether the CMP imposed against Petitioner is reasonable, I apply the factors listed in 42 C.F.R. § 488.438(f).  42 C.F.R. § 488.438(e)(3).  These factors include:  1) the facility’s history of noncompliance; 2) the facility’s financial condition; 3) the factors specified in 42 C.F.R. § 488.404; and 4) the facility’s degree of culpability, which includes neglect, indifference, or disregard for resident care, comfort or safety.  42 C.F.R. § 488.438(f).  The absence of culpability is not a mitigating factor.  Id.  The factors in 42 C.F.R. § 488.404 include:  1) the scope and severity of the deficiency; 2) the relationship of the deficiency to other deficiencies resulting in noncompliance; and 3) the facility’s prior history of noncompliance in general and specifically with reference to the cited deficiencies. 

I consider whether the evidence supports a finding that the amount of the CMP is at a level reasonably related to an effort to produce corrective action by a provider with the kind of deficiencies found, and in light of the above factors.  I am neither bound to defer to CMS’s factual assertions nor free to make a wholly independent choice of remedies without regard for CMS’s discretion.  See, e.g., Barn Hill Care Ctr., DAB No. 1848 at 21 (2002).  Unless a facility contends that a particular regulatory factor does not support the CMP amount, an ALJ must sustain it.  Coquina Ctr., DAB No. 1860 (2002). 

At the time of the initial survey, the baseline CMP range was from $1,000 to $10,000 prior to adjustment for inflation.  42 C.F.R. § 488.438(a)(2).  With inflation adjustment, the CMP range was $2,400 to $23,989.  See 87 Fed. Reg. 15,100 (March 17, 2022); 45 C.F.R. § 102.3 (2022).  CMS imposed a per-instance CMP of $12,605 for the noncompliance with 42 C.F.R. § 483.25(d).  

Petitioner does not argue that it is unable to pay the CMP amount or that any history of noncompliance should affect the amount of the CMP.  Heritage Plaza Nursing Ctr., DAB No. 2829 at 22 (2017). 

Petitioner’s deficiency was at the immediate jeopardy level, and Petitioner failed to provide the supervision and assistance devices necessary to prevent Resident 1’s elopement.  Petitioner argues throughout its filings that any deficiencies found were not at the immediate jeopardy level.  However, even if this deficiency did not amount to immediate jeopardy, which I do not find, a per-instance CMP at the mid-range of the penalty range is entirely appropriate for a deficiency that resulted in a resident, who was diagnosed with schizoaffective disorder, schizophrenia, psychosis, and psychoactive substance dependence, eloping and going missing for many hours.  A $12,605 per-instance CMP is reasonable.  

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IV. Conclusion

For the reasons discussed above, I find that the facility was not in substantial compliance with the Medicare participation requirements.  A $12,605 per-instance CMP is reasonable.