Every finding on record at Encore at Turf Valley

Based on observations and interviews with facility staff, it was determined the facility failed to ensure that foods that were stored in the refrigerator and freezer had a date when prepared and opened. This was found to be evident during an initial tour of the kitchen during the survey. The findings include: An initial tour of the kitchen was conducted on 5/8/25 at 8:30 AM with the Dietary Manager (#6) and Kitchen Supervisor (#5) present and the following concerns were identified. Further observations were made of the stored refrigerator foods, and the following items were identified: 6 large silver trays of French fries with no date on it. 5 large silver trays of biscuits with no date on it 2 large silver trays of turkey sausage with no date on it 28 large silver trays of bacon with no date on it 1 (2 lb) bag of Pepper jack cheese cubes opened with no date when opened 1 (2 lb) bag of Swiss cheese cubes opened with no date when opened. Inside the Freezer there was a large silver tray with 4 frozen fruit pies with no date on it and a 1/2 bag of frozen biscuits with no date when it is opened. The DON was made aware of all concerns on 5/8/25 at 11:45 AM. All concerns were discussed with the Administration team at the exit conference on 5/14/25 at 2:30PM

2. During observation rounds on 5/8/25 at 9:00 AM, Resident #18 was observed lying in bed near the window, with the bed in its lowest position. The resident was uncovered with a brief exposed; the resident's curtain was open and the resident could be seen from the hallway by staff or visitors. The resident was yelling to help get to their tray. The resident tray was located on the bedside table and the bedside table was observed pushed against the wall in a high position. The resident stated my tray is often left on the table and not given to me when my meals are served. This surveyor informed the Licensed Practical Nurse (LPN #11) of the observation on 5/8/25 at 9:10am. She stated the tray should not have been left in the room without setting the tray up for the resident and she would take care of it. Based on observation, interview, and record review, it was determined that the facility failed to promote care in a manner that maintains dignity and respect and failed to ensure that meal trays were appropriately presented to residents requiring assistance. This deficient practice was evident for 2 of 15 residents reviewed (Residents #18 and #29) during the survey. The findings include: 1. During the surveyor's initial tour of the facility on 5/8/25 at 8:32AM the surveyor observed Resident #29 lying in their bed awake and reaching their arms in an upward motion. Resident #29's tray holding their breakfast meal and water cup was observed by the surveyor sitting on their nightstand furniture. No staff were observed present within the resident's room. Review of the medical record by the surveyor on 5/13/25 at 12:41PM revealed assessment documentation of the resident's eating habits on the Resident Summary V2 form dated 5/1/25 which indicated the resident required assistance from staff and was dependent on staff for eating. Review of the medical record of Resident #29 by the surveyor on 5/13/25 at 1:38PM revealed a nutrition note dated 5/12/25 which documented the following information: S/he is encouraged and assisted by staff at mealtimes, feel current interventions remain appropriate. On 5/14/25 at 10:46AM the surveyor conducted an interview and shared the concern with the facility's Director of Nursing (DON) who acknowledged and confirmed understanding of the surveyor's concern. During the interview the DON acknowledged that staff had passed the trays prior to providing feeding assistance to residents who required it on 5/8/25 and after intervention by the survey team they had provided education to staff regarding the procedure for passing resident meal trays and feeding assistance. On 5/14/25 at 1:41PM the surveyor reviewed the facility's policy for feeding residents which was observed to include the following information: Hold resident tray on cart to maintain temperature until the end of tray pass or until ready to assist with feeding. On 5/14/25 at 2:00PM the concern was reviewed with the DON and the Administrator during the facility's exit conference.

Based on record review and an interview, it was determined that the facility failed to ensure that residents were provided written information regarding their right to formulate an advance directive upon admission This was evident for 2 (Residents #13, #62) out of 6 residents reviewed for Advance Directives. The findings include: According to the Centers for Medicare and Medicaid (CMS) the definition of an Advance Directive is a document that appoints an agent and records a patient's medical treatment wishes based on their values and preferences. Advance Directives can be different from state to state. On 05/08/2025 at 1:13 PM, a review of the electronic medical records for Residents #13 and #62 revealed no documentation of advance directives or evidence that the residents had been provided with information about their rights to establish one at the time of admission. At that time, the surveyor requested the Director of Nursing (DON) assist in locating any documentation related to the advance directive discussions or provision of information. On 05/12/25 at 08:05 AM, the DON brought documentation of contact with the two residents' responsible parties. The request for Resident #13's advance directive was dated 05/08/24 at 08:54 PM and Resident #62's responsible party was contacted on 05/09/25 at 3:22 PM. During an interview on 05/14/25 at 12:29 PM, the DON stated that the facility's process for handling advance directives includes requesting the information at admission, followed by contacting the resident's family to locate and provide the documents. On 05/14/25 at 1:15 PM, the DON provided a progress note dated 03/28/25, which stated: Social work addressed status of advance directives for health. However, the facility was unable to provide any signed documentation verifying that information about advance directives was presented to the resident upon admission, or at any other point thereafter.

Based on interview and record review it was determined the facility failed to notify the physician of a resident's change in condition in a timely manner. This was evident for 1 (Resident #83) out of 1 resident reviewed for neglect during the survey. The findings include: On 5/8/25 at 8:30AM the surveyor requested the medical record of Resident #83 from the facility's Director of Nursing (DON) after review of complaint MD00204946. Review of the medical record by the surveyor on 5/9/25 at 2:31PM revealed documentation of Resident #83's blood pressure reading of 88/52 on 4/6/24 at 8:51PM. On 5/9/25 at 2:31PM the surveyor requested from the facility's DON, all documentation of notification to Resident #83's physician of the blood pressure reading of 88/52. On 5/13/25 at 9:44AM the surveyor reviewed the e-medical notification message provided by the DON which was dated 4/6/24 at 9:13PM from Licensed Practical Nurse (LPN) #15 to Physician #16 which revealed Resident #83 had the following vital signs at 5:00PM on 4/6/24: blood pressure of 74/42, pulse of 52, O2 of 92, and by 5:30PM on 4/6/24 they had a blood pressure of 88/52, and at 8:00PM on 4/6/24 they had a blood pressure of 68/42 and a pulse of 99 and 2 liters of oxygen was in place and medication was held by the nurse. The surveyor noted that the initial vital sign changes documented by LPN #15 as beginning at 5:00PM were not communicated to Physician #16 until approximately 4 hours and 13 minutes after the changes began, at which time Physician #16 then provided a response on 4/6/24 at 9:34PM. On 5/14/25 at 8:35AM surveyors provided an opportunity for the DON to provide any and all further documentation that the physician was notified of the vital sign changes of the resident prior to 9:13PM on 4/6/24. In response to the surveyor's request, the DON stated the following information to surveyors: I don't know if the physician was in the building and it was an fyi (for your information) to the nurse from the physician. When the surveyor inquired to the DON as to if communication regarding the resident's medical status should be documented in the resident's medical record, they responded: Yes. On 5/14/25 at 8:45AM the surveyor conducted an interview with the DON who reported to surveyors that there was no documentation of notification of the resident's condition change to the physician prior to 9:13PM on 4/6/24. On 5/14/25 at 10:46AM the surveyor shared the concern with the DON who acknowledged and confirmed understanding of the concern. On 5/14/25 at 2:00PM the concern was reviewed with the DON and the Administrator during the facility's exit conference.

Based on observation and staff interview, it was determined that the facility failed to ensure the confidentiality of resident records by allowing protected health information (PHI) to remain visible on an unattended computer screen at the main nursing station. This failure resulted in unauthorized exposure of resident names, insurance payor information, and care levels for 27 residents. The findings include: On 05/08/25 at 8:45 AM, an observation was made of an unattended computer screen at the main nursing station displaying protected health information (PHI). The screen was clearly visible to anyone passing by, and it listed the names of 27 residents, along with their insurance payor information and care level. The screen faced an area that visitors and residents can access and from which the information would be readable. No staff member was present at the station during the observation. On 05/13/25 at 12:47 PM, an interview was conducted with the Director of Nursing (DON), who confirmed that PHI should not be left visible or accessible when unattended. The DON acknowledged that the screen should have been locked or turned off to prevent unauthorized viewing and affirmed that the information displayed constituted PHI.

Based on record review and interview with facility staff, it was determined that the facility failed to timely report allegations of abuse within the required two-hour timeframe to the Survey Agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (MD00199783) of 2 facility related incident reports reviewed during the survey. The findings include: On 05/12/25 at 9:53 AM, it was determined that the facility failed to report an allegation of abuse in a timely manner for Resident #13. The incident was reported to the facility on [DATE] at 2:00 PM but was not submitted to the Office of Health Care Quality (OHCQ) until 11/21/23 at 10:00 AM, exceeding the required reporting timeframe of within 2 hours for allegations of abuse. During an interview on 05/13/2025 at 12:45 PM, the Director of Nursing stated that the facility's policy and expectation is that all abuse allegations are to be reported within two hours of being made known to staff. This confirmed that the reporting of the allegation involving Resident #13 was not in accordance with this expectation.

Based on record review and interviews with staff, it was determined that the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #87) out of 25 residents reviewed during the investigative portion of the survey. The findings include: On 5/13/2025 at 9:45AM, during a review of Resident #87's electronic medical record, the Surveyor discovered that the resident was admitted to the facility on [DATE] for rehab after hospitalization for a right revision total knee replacement and infection associated with internal right knee prosthesis with a wound vac in place. MDS section GG0115 is Functional Limitation in Range of Motion. Residents are coded for limitation that interfered with daily functions or placed the resident at risk of injury in the last 7 days. Coding for 0=no impairment, 1 = Impairment on one side, and 2 =Impairment on both sides. Code boxes A. Upper extremity (shoulder, elbow, wrist, hand) and B. Lower extremity (hip, knee, ankle, foot). On 5/13/2025 at 10:00AM, a review of Resident #87's Admission MDS assessment dated [DATE] revealed that in Section GG0115, Functional Limitation in Range of Motion, the resident was coded 0, which indicated no impairment, in box B lower extremity (hip, knee, ankle, foot). Further review revealed the resident needed substantial/maximal assistance during the admission performance of lower body dressing, rolling left to right, sit to lying, lying to sitting on the side of the bed, sit to stand, chair/bed-to-chair transfer, and toilet transfer. On 5/13/2025 at 11:55AM, during an interview conducted with Physical Therapy staff #17, the Surveyor was informed that the resident had impairment of the right lower extremity due to surgery on the right knee. The resident had limited range of motion (ROM) at -10 degree's extension and 72 degree's flexion, with a goal to increase the right lower extremity ROM 10 degrees by discharge. A review on 5/13/2025 at 12:10PM of Resident #87's occupational therapy evaluation from 8/19/2024, revealed that under the section for Musculoskeletal ROM, the right lower extremity was impaired and under the section for pain, the resident experienced pain in the right knee. On 5/13/2025 at approximately 12:45PM, during an interview conducted with the MDS Coordinator #8, the Surveyor confirmed that Resident #87 had functional impairment of the right lower extremity due to right knee surgery. The resident should have been coded in section GG0115 for 1, impairment on one side, in box B for lower extremity. On 5/14/2025 during an interview with the Director of Nursing (DON), the Surveyor expressed the concern that Resident #87 had not been coded for functional impairment of the right lower extremity during the Admission MDS assessment done on 8/19/2024.

Based on observation, medical record review and staff interview, the facility failed to ensure a resident receives the correct diet as ordered by the physician. This was evident for 1 (Resident #133) of 23 residents observed during the survey. The findings include: On 5/8/25 at 08:30 AM, an initial observation of Resident #133 revealed the resident had the wrong breakfast tray delivered to his/her room. A Review of the meal ticket located on the tray revealed the tray belonged to Resident #74. On 5/8/25 at 8:35am the GNA (Geriatric Nursing Assistant) staff #10 entered the room carrying another tray for Resident #133. When asked about the tray that was already delivered to the resident he stated, I don't know who brought the other tray into this room, but this has the resident name on it. Staff #10 removed the incorrect tray. The LPN (Licensed Practical Nurse) staff #11 were made aware of the findings, she stated an agency GNA put the tray in the resident room in error. On 5/8/25 at 10:21 AM, Resident #133's medical record revealed a physician order for a regular diet. A Review of Resident #74's medical record revealed a physician order for a Dysphagia Level 2 diet, also known as the Dysphagia Mechanically Altered diet, focuses on moist, soft -textured foods that are easy to chew and swallow. On 5/9/25 during an interview with the DON (Director of Nursing) she stated staff #11 made her aware of the incident.

Based on interview and record review it was determined the facility failed to ensure accuracy of medical assessment documentation of a resident. This was evident for 1 (Resident #38) out 3 residents reviewed for pressure ulcer/injury during the survey. The findings include: On 5/8/25 at 2:26PM the surveyor conducted a review of the medical record for Resident #38 which revealed skilled progress note documentation on 2/1/25 of the resident's skin integrity by Licensed Practical Nurse #13 which indicated the resident had sacrum wounds. On 5/13/25 at 2:35PM the surveyor reviewed the February 2025 Treatment Administration Record (TAR) which documented weekly skin assessments performed by various nursing staff indicating the resident's skin was intact. Further review of the February 2025 TAR by the surveyor on 5/13/25 at 2:37PM revealed additional skin assessments performed twice weekly by various nursing staff on the resident's shower days which indicated the resident's skin was intact. No change of condition or additional documentation regarding new or existing sacral wounds could be found within the resident's medical record. On 5/14/25 at 10:28AM the surveyor conducted an interview of the facility's Assistant Director of Nursing (ADON) who confirmed with the surveyor that Resident #38 did not have any sacral wounds. The surveyor shared their concern with the ADON who stated they would review the resident's medical record. On 5/14/25 at 10:31AM the surveyor conducted an interview with Registered Nurse (RN) #14 who was assigned care of Resident #38. During the interview RN #14 confirmed they had performed skin assessment of the resident and their skin was intact with no concerns. On 5/14/25 at 11:49AM the ADON approached the surveyor to inform that Resident #38 did not have any sacral ulcers/concerns and the 2/1/25 documentation was incorrectly documented and would be corrected. On 5/14/25 at 12:30PM the surveyor shared the concern with the Director of Nursing (DON) who acknowledged and confirmed understanding of the concern and stated the following information to the surveyor regarding the 2/1/25 documentation: It should be striked [sic] out, it was in the wrong chart. On 5/14/25 at 2:00PM the concern was reviewed with the DON and the Administrator during the facility's exit conference.

Based on observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and procedures to prevent the transmission of dirt and germs when storing dish trays in the kitchen. This was found to be evident during observations made in the kitchen during the survey. The findings include: An initial tour of the kitchen was conducted on 5/8/25 at 8:30AM with the Dietary Manager (# 6) and Kitchen Supervisor (5) present and the following concerns were identified: Dish Crates observed on the floor next to the Dishwasher, across from the Dishwasher and stored on the floor. There were greater than 10 crates stored on the floor. The surveyor asked if dish crates are to be stored on the floor and the DM stated, no. At this time, he picked up all the trays and ran them through the dishwasher to clean them. The DON was made aware of all concerns on 5/8/25 at 11:45 AM. All concerns were discussed with the Administration team at the exit conference on 5/14/25 at 2:30PM

Based on observation, interview, and documentation review it was determined that the facility staff failed to store, prepare, and maintain a sanitary environment in accordance with professional standards for food service safety by failing to ensure that Dishwasher hot water temperatures are frequently checked to ensure the cleanliness and sanitation of dishware, failing to ensure proper cooking temperatures of food by taking temperatures during food preparation and service and failing to store dishware sanitarily. This practice had the potential to affect all residents that consumed food that was prepared by the kitchen. The findings include: An initial environmental kitchen food services inspection was conducted on 11/15/21 at 8 AM. Observations of the dishwasher area revealed that there were approximately 40 bowls of various sizes in 5 stacks with bowl side up and 4 coffee cups stored on top of the dishwasher. Dishwasher temperature check logs were not observed. The Dinning Services Manager was in the kitchen at the time of the inspection and was asked to provide copies of the last two county inspection reports among other dietary information. A second kitchen inspection was conducted on 11/17/21 at 10:10 AM. The stored dishware on top of the dishwasher remained in place. The Dinning Services Manager was interviewed at 10:20 AM related to the observed dishware storage on top of the dishwasher. He indicated that the dishware should not be stored on top of the dishwasher and indicated that he will have his staff remove the items for proper storage. He was asked to show current food temperature logs and he opened a binder to show that the recording of prepared food temperatures for tray line had not been recorded in the past 7 days. The last recorded meal/food temperatures were documented on 11/10/21. He did not have food temperatures for the current day's breakfast meal. Additionally, there was not any recording of food temperatures for dinner on 11/2/21. I asked him for the food temperature logs for the month of October 2021. He indicated that he would have to look for them. He did not provide the food temperature logs as requested from the previous month. Dishwasher temperature logs were not found/observed in the dish washing machine area or any other area in the kitchen. The Dinning Services Manager was interviewed again. He indicated that he does not have recorded temperature checks. He could not show me that the dishwasher sanitation was reviewed at each mealtime when dishware and utensils are washed. The lunch time tray line service started at 12:10 PM on 11/17/21. Prior to the tray line starting review of the food temperature logbook did not reveal any documentation of the food temperatures for the meal being served. The Cook (staff #31) who was putting the food on the plates was not observed to measure the temperature of the food prior to food tray line service. Staff #31 was interviewed at 12:15 PM about taking food temperatures. She indicated that she writes/records them later. I asked about the preparation of the Chile that was being served on the tray line and she indicated that the Chile was made from scratch using raw ground beef. The Dining Service Manager was washing dishes as the food tray line service was being conducted. At 12:25 PM [11/17/21] he was informed of what the Cook (staff #31) indicated about the food temperatures, and he came to the tray line and began taking and documenting food temperatures. Copies of the last two Local County Heath Department inspections were reviewed at 1 PM on 11/17/21. The last health department inspection occurred three weeks prior to the 28th of October. The inspection report revealed that the warewashing facilities were out of compliance. Have dish machine serviced within 7 days. Send confirmation of service. Facility may use dish machines to wash dishes but must then sanitize using 3 compartment sinks . On 11/17/21 at 2:42 PM the Dining Service Manager brought Dishwasher temperature logs to the surveyor in the conference room. He provided logs for November, October, September, and August. The logs were initialed by him for every single entry on the 4 forms. Every entry was documented the same with a wash temperature of 165°F (Fahrenheit) and a rinse temperature of 195°F. The documents shown that the wash and rinse levels were 165°F and 195°F on the days the county health department cited the facility for the dish washer being out of compliance. On 11/24/21 at 2:10 PM while in the kitchen the Dining Service Manager was asked to show the current dishwashing log. He looked for the log stating, did someone move it out of my office. When he found it on a clip board, there was not any recorded temperatures for 11/23/21 and 11/24/21. The concerns of the kitchen were reviewed with the Nursing Home Administrator on 11/24/21 at 4:45 PM.

Based on medical record review and staff interview, it was determined the facility failed to develop and implement comprehensive person-centered care plans with appropriate measurable goals. This was exemplified for 3 (#69, #63, #24) residents out of 46 residents reviewed. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident. The Minimum Data Set (MDS) is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Maryland Order for Life Sustaining Treatment (MOLST) - This term refers to a document which is the written instructions when the resident becomes unable to make their own decisions (medical and preferences). 1) Review of Resident #69's medical records revealed that the resident was admitted to the facility on [DATE] for complications after a stroke. The resident's medical records also revealed that the resident's MOLST (Maryland Order for Life Sustaining Treatment) dated 1/14/18 indicated instructions to not give life-saving care and only comfort care if the resident is unable to breathe on his/her own. Further review of Resident #69's medical records dated 9/27/21 revealed that the facility nursing staff was aware that the resident was receiving comfort care. Interview with Director of Nursing (DON) on 11/19/21 at 10:19 AM revealed the resident's care plan did not include comfort care as one of the resident's treatments. Interview with the primary care provider (staff #30) on 11/19/21 at 10:56 AM revealed that the resident was receiving comfort care interventions since admission to the facility. The surveyor pointed out the lack of comfort care interventions in the resident's care plan. Upon interview, Staff #30 was unable to give a reason why Resident #69's care plan failed to contain comfort care interventions. The surveyor expressed concerns about the accuracy of Resident #69's care plan in an interview with the DON and the Administrator on 11/24/21 at 4:50 PM. 2) Resident #24's medical record was reviewed on 11/17/21 2:38 PM. Review of Minimum Data Set (MDS) assessments dated 6/9/21 and 9/17/21 revealed that Resident #24 was frequently incontinent of bowel and bladder. Review of the resident's care plans failed to reveal a care plan with specific interventions and approaches to manage the resident's assessed frequent incontinence. 3) On 11/15/21, at 12:43 PM a record review was conducted for Resident # 63. Resident # 63 has a history of [CONDITION(S)] and shortness of breath. The resident will not wear O2 (oxygen) continuous per her choice. The doctor Ordered O2 at 2 liters via Nasal Canula PRN (as needed) if pulse ox is less than 92 %. There was no baseline or comprehensive care plan for use of oxygen. On 11/16/21 08:24 AM a review was conducted for Resident # 48. The resident has a history of [CONDITION(S)] and [CONDITION(S)] ([CONDITION(S)]). On 8/23/21 the resident had a chest x ray for coughing and congestion. The results indicated early stages of developing perihilar pneumonia with underlying [CONDITION(S)]. The resident was placed on antibiotic therapy [MEDICATION(S)] 750 mg, started 8/24/21 x 7 days, for Pneumonia. The head of bed is elevated to prevent shortness of breath. On 8/31/21 WBC (white Blood Cells) were high . The SBAR (Change of condition form) was done on 8/22/21, however there was no comprehensive care plan for [CONDITION(S)] or [CONDITION(S)].

Based on medical record review and interviews with staff and a resident, it was determined that the facility failed to ensure an interdisciplinary team, which included the resident and or the resident's representatives, contributed to the resident's comprehensive care plan as evidenced by the failure to conduct a quarterly care plan meeting. Additionally, facility staff failed to document and evaluate each care plan to ensure the interventions continued to be appropriate for the resident's condition. This was found to be exemplified for 6 (Residents #29, #22, #49, #24, #123, #69) out of 46 resident's reviewed during the survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool used to identify resident needs and help with the development of the resident's plan of care. The MDS assessments are federally mandated to be completed at least quarterly with additional assessment information required during the annual assessment. Care Plan refers to a document which is the written plan of how a long-term care facility will provide care. This plan is based on resident health assessments, preferences and goals. 1) Review of Resident #29's medical record on 11/18/21 revealed the resident has resided at the facility for more than a year, was cognitively intact and able to make their needs and wishes known. Further review of the medical record revealed the resident had an annual Minimum Data Set (MDS) assessment completed 3/30/21 and quarterly assessments completed 6/30/21 and 9/29/21. The expectation is that a care plan meeting, which would include the resident, occurs after each of these assessments. On 11/18/21 at 11:46 AM the Social Service Director (SSD #7) reported that the Social Service Assistant (SSA #11) facilitates Resident #29's care plan meetings. On 11/18/21 at 11:55 AM the SSA #11 reported that she facilitates the care plan meetings for the long term care residents. She confirmed that she does not review the items in the care plan. During a follow up interview at 12:15 PM the SSA #11 SSA #11 provided documentation that a care plan meeting had occurred in April, but confirmed no care plan meeting since then. Review of the documentation of the 4/2/21 care plan meeting revealed the resident, the resident's health care agent and SSA #11 were the only attendees at the April care plan meeting. During the 11/18/21 12:15 PM interview the SSA #11 reported that they had attempted to schedule a meeting over the summer but had not received any call back from the family member. She confirmed that the resident was his/her own responsible party. She went on to report that they do not have a formal care plan meeting if neither the resident or the family respond to the invitation. She confirmed that there was no documentation in the medical record of attempts to schedule this meeting. On 11/24/21 at 2:50 PM surveyor reviewed with the Director of Nursing the concern regarding failure to ensure care plan meetings occurred after quarterly MDS assessment. Cross reference to F 578 2) Resident #49's medical record was reviewed on 11/17/21 at 9:30 AM. Resident #49 was admitted to the facility in December of 2018. Review of the resident care plans revealed a care area documented as I am on Antibiotic therapy and another area as I am on diuretic therapy. Both care plans were initiated in November of 2018. MDS assessment reviews of Section N for assessment dates of 12/4/20, 7/3/21, and 10/1/21 indicated that the resident was not receiving antibiotics or diuretics. Review of the most current physician's orders did not reveal prescriptions for antibiotics or diuretics. Documented care plan evaluations were not found in the medical record. The current target date for both care plans was documented as 7/24/2021. An interview was held with the social worker (staff #7) on 11/18/21 at 9:05 AM. The Social Worker indicated that she was responsible for writing the care plan meeting notes. She indicated that she has documentation in her office that she needs to scan into resident's medical records. She asked if there were specific care plan documentation that were needed. The surveyor asked for all the documentation. The social services assistant (staff #11) was interviewed at 12:28 PM on 11/18/21. A care plan note that she had written on 7/8/21 was reviewed with her. She had written that the resident's son and the interdisciplinary team were in attendance of a care plan meeting on 7/8/21. The social services assistant acknowledge that she did not document the resident's participation or reason of the resident's non-attendance in her care plan note. A quarterly MDS assessment was completed for 10/1/21. There were not any social work or social services notes for an October meeting. Staff #11 collaborated that there was not any documentation of a meeting held for the quarterly assessment of 10/1/21. 3) Resident #24's medical record was reviewed on 11/17/21 2:38 PM. Resident #24 was admitted to the facility in August of 2018. Review of the current care plans revealed an area of focus initiated on 8/30/18 and documented as Resident has the potential for altered adjustment due to new admission to the facility related to altered mood status. The goal for this focus care area was written as I will exhibit signs of adjusting to facility environment within 7 days of admission. The current documented target date was dated 6/30/21. Documented care plan evaluations were not found in the medical record. Review of the social services notes revealed that a care plan meeting was held on 9/9/21 with the resident and resident's sister included in the meeting. Review for previous quarterly care plan meeting documentation revealed that a year had transpired between care plan meetings as the previous care plan meeting was documented on 9/15/20 at 11 AM. 4) Resident #22's medical record was reviewed on 11/17/21. Review of the medical record revealed that the resident was readmitted to the facility in June of 2021 and the resident had an admission Minimum Data Set (MDS) assessment completed 7/3/21 and quarterly assessment completed 10/2/21. The expectation is that a care plan meeting, which would include the resident, occurs after each of these assessments. Further review of the medical record did not reveal any social worker, social services, or care plan meeting notes. There was not any documentation that the resident or the resident's responsible paper had the chance to attend and participate in a care plan meeting. 5) On 11/19/21 at 2:35 PM the medical record and incident report were reviewed for resident # 123. Resident # 123 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient was found at times with his leg positioned inward or would lean forward in his wheelchair. Resident transferred to the hospital at 5:45 PM on 4/21/21 after resident complained of pain and 1 leg was shorter than the other. X-ray received and resident had dislocated right hip. Resident returned to the facility on [DATE] with new orders to wear leg brace at all times but not with abduction pillow. The was no change or update to care plan since returning from the hospital. Care Plan is not individualized. 6) Review of Resident #69's medical records revealed that the resident was admitted to the facility on [DATE] for complications after a stroke. The resident's medical records also revealed that the resident's MOLST dated 1/14/18 indicated instructions to not give life-saving care and only comfort care if the resident is unable to breathe on his/her own. (MOLST - This term refers to a document which is the written instructions when the resident becomes unable to make their own decisions (medical and preferences). Further review of Resident #69's medical records dated 9/27/21 revealed that the facility nursing staff was aware that the resident was receiving comfort care based on the resident and his/her family's preferences. Interview with Director of Nursing (DON) on 11/19/21 at 10:19 AM revealed the resident's care plan did not include comfort care as one of the resident's treatments nor did the facility attempt to update the care plan when nursing staff became aware that comfort care interventions were the preferences of the resident and his/her family. Interview with the primary care provider (staff #30) on 11/19/21 at 10:56 AM revealed that the resident was receiving comfort care interventions since admission to the facility. The surveyor pointed out the lack of comfort care interventions in the resident's care plan. Staff #30 was unable to give a reason why Resident #69's care plan failed to contain comfort care interventions. The surveyor expressed concerns about the accuracy of Resident #69's care plan in an interview with the DON and the Administrator on 11/24/21 at 4:50pm.

Based on medical record review and interview it was determined that the facility failed to ensure staff followed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was found to be evident for 4 (Resident #29, # 15, #169, #173) out of 46 residents reviewed during the survey. The findings include: 1) On 11/18/21 review of Resident #29's medical record revealed the resident has diabetes and an order, in effect since December 2020, to check the resident's glucose (blood sugar level) before breakfast and at bedtime. Review of the October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The concern rgarding the failure to obtain the blood sugar level as ordered for 3 mornings in a row was reviewed with the Director of Nursing (DON) on 11/24/21 at 2:50 PM. 2) On 11/23/21 review of Resident #169's medical record revealed the resident was admitted to the facility earlier in the month with diagnsosis that include but not limited to [CONDITION(S)] and dementia. Review of the care plan, established 11/15/21 revealed: I have a swallowing problem related to difficulty with thin liquids. Review of the paper chart revealed revealed an order, dated 11/15/21: per SLP [speech language pathologist] .No Straws . Further review of the medical record failed to reveal an order to discontinue the order for No Straws. On 11/23/21 at 12:09 PM the resident was observed in his/her room by him/herself. There was a cup of water with a straw observed within reach of the resident. Surveyor alerted nurse #26, who was assigned to care for the resident at this time. The nurse removed the cup with the straw and reported that maybe the aide had brought it in. On 11/23/21 at approximately 12:30 PM the Speech Therapist (ST #30) reported the resident had been experiencing silent aspiration (when fluid enters the lungs but usually has no symptoms) while in the hospital. The ST #30 confirmed the recommendation was still for the resident to have no straws. On 11/23/21 at 12:56 PM Geriatric Nursing Assistant (GNA #19) confirmed she was assigned to care for Resident #169 today. Reported that she can ask the therapists or review the chart to find out the resident's care needs. The GNA was unsure if she had access to the care plans but stated that some information was availble in the point of care (the computer software used for GNAs to document care). The GNA denied knowledge of any precautions in regard to eating or drinking. Confirmed that she would give the resident a drink with a straw in it. Surveyor requested the GNA speak with the nurse regarding the use of a straw. On 11/23/21 at 3:49 PM reviewed with the DON the concerns regarding the failure to ensure the order for No Straws was communicated to the GNA assigned to care for the resident. The DON reported that GNAs are usually given report from the nurse and that the therapist will also update them regarding the needs of the resident. The DON confirmed that the GNAs do not have access to the care plan. On 11/24/21 at 11:52 AM the DON reported that she had added the No Straws intervention to the care tracker (used to communicate information to the GNAs). DON later provided a copy of the Task List Report for this resident which revealed the No Straws intervention had been added on 11/24/21. On 11/24/21 GNA #19 was able to demonstrate that she now has access to the No Straw intervention from her point of care access. On 11/24/21 at 2:50 PM surveyor reviewed with the DON the concern regarding failure to follow the order for No Straws and failure to have a system in place to ensure GNAs can access the care plan interventions. 3) Review of Resident #15's medical record on 11/17/21 revealed the resident was admitted in 2021 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic health record (computer) revealed a current active order, orginally written on 6/19/21, for a speech consult. Further review of the paper chart revealed that on 6/19/21 a nurse had sent a communication to the Nurse Practitioner with a concern regarding the amount of food the resident was consuming and requested a speech consult to evaluate for a pureed diet. The Nurse Practitioner agreed with the request. The primary care physician had signed the order on 7/19/21. Further review of the medical record failed to reveal documentation to indicate speech therapy had completed an evaluation after the 6/19/21 order. On 11/17/21 at 2:27 PM the Therapy Director, who is a Speech Therapist (ST #22), reported that her access to the electronic health record did not include the physician orders. When asked how therapy is informed of orders for evaluations, she responded that the nurse usually tells them, or gives them a copy of the order. The Therapy Director reported that she did not recall receiving an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/17/21 at 2:55 PM surveyor reviewed with the Unit Nurse Manager (nurse #5) the concern that, based on interview with Therapy Director, there was no indication that 6/19 speech evaluation had been completed as ordered. On 11/23/21 at 4:12 PM the Director of Nursing (DON) reported that in regard to therapy evaluation orders the nurse will communicate directly with therapy and let the supervisor know, and typically will send an email to therapy and the DON. She was unable to provide any documentation or information as to if this had occurred in regard to the 6/19/21 order for the speech evaluation. Surveyor reviewed the concern with the DON that the nurse contacted the practitioner with a concern; there is a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 4) A review of Resident #173's medical record on 11/17/21 at 9:38 AM revealed the resident was admitted to the facility on [DATE] with a Foley catheter from an acute care facility. Review of the hospital discharge summary dated 11/4/21 showed the resident needed a follow-up appointment with a Urologist. Further review found an order from the resident's physician dated 11/5/21 that stated 'consult/appointment with Urology for Urinary retention'. Further medical record review revealed Resident #173 observed red urine draining on 11/7/21 by the facility staff. A facility physician ordered 'have the patient follow up with urology ASAP (as soon as possible)' on 11/8/21. However, there was no documentation found to support that the facility arranged a follow-up visit for the resident with the Urologist until the surveyor team alerted the facility staff on 11/17/21 at 11:30 AM. An interview was conducted with the Assistant Director of Nursing (ADON) on 11/17/21 at 9:17 AM, who stated that the Unit Clerk (staff #12) was responsible for scheduling residents' appointments. An interview was conducted on 11/17/21 at 9:50 AM with Staff #12. Staff #12 verified that Resident #173 had no scheduled appointments with a Urologist since he/she had been admitted at this facility. An interview with the ADON was conducted on 11/17/21 at 12:37 PM. During the interview the ADON stated the initial order dated 11/5/21 for a Urologist follow-up included an end date of 11/6/21, so the order was dropped. The ADON added, Resident #173's order dated 11/8/21 was transferred to the unit clerk via email but the person who sent the order failed to alert the clerk that an order was sent. The ADON added that we just made Resident #173's Urologist appointment on this Friday (11/19/21). Based on Medical record review, the facility failed to write a change of condition (SBAR) on the SBAR form for Resident # 48. This was evident for 1 out of 8 residents reviewed for change of conditions. The findings include: On 11/16/21 at 8:24 AM a record review was conducted. Resident # 48 has a history of Benign [CONDITION(S)] with lower tract urinary symptoms. On 9/8/21 a note was written in the chart at 18:33 hours that the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing called the doctor and he responded; this is not an emergency that Friday will be fine for the ultra sound. There was no change of condition form (SBAR) completed related to the resident having hematuria or any documentation on this.

Based on medical record review and staff interview it was determined the facility staff failed to have a process to ensure that medication regimen reviews occur monthly for all residents and pharmacist recommendations were timely acted upon and documented in the resident's medical record. This was evident for 3 (#49, #56, #52) of 5 residents reviewed for unnecessary medications. Additionally, the facility failed to develop policies and procedures related to the steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. The findings include: 1) Resident #49's medical record was reviewed on 11/18/21 at 8 AM. Documentation of monthly medication pharmacy reviews were not found in the resident's medical record. An interview was conducted with the Director of Nursing (DON) on 11/18/21 at 8:22 AM. She was asked to provide the location of the monthly pharmacy medication reviews. She indicated that the previous pharmacy was performing medication reviews quarterly. She indicated that she gets a monthly list and information sent to her by the consulting Pharmacist. She was asked to provide the facility policy and procedures related to the Monthly medication review and documentation of monthly pharmacy reviews. At 12:02 PM on 11/18/21 the DON provided an undated Policy and Procedures for Monthly Medication Review. She provided 8 monthly list of Consultant Pharmacist's Medication Regimen Review from October back to March of 2021. She indicated that current pharmacy changed in March 2021. She could not provide documentation prior to March 2021 as she did not have access to the previous pharmacy's portal to obtain records. The monthly medication review lists only identified residents that were reviewed during the consultant pharmacist's visit but did not require any recommendations. Resident #49 was not listed on the medication review for July 2021. Review of both the paper chart and the electronic health record (EHR) did not reveal a separate written report identifying the relevant medication and the irregularity that the pharmacist identified. At 3:00 PM on 11/18/21 the DON was asked if she could find a recommendation by the pharmacist in July 2021. At 3:20 PM she returned and acknowledged that she did not find the pharmacist recommendation with a response from the attending physician. The DON provided a copy of the Note to attending physician/Prescriber dated 7/16/2021 and dated as printed on 7/16/21. The pharmacist identified an irregularity related to the prescribed use of an antipsychotic medication and a request for a Gradual dose reduction (GDR). The form did not have any indication that the residents attending physician reviewed the document as the form was void of a physician response. Further review of the medical record did not reveal any documentation of action taken to address the pharmacist recommendation or a rationale for not addressing the recommendation. On 11/19/21 at 8:35 AM an interview was conducted with the DON to review the documentation system that the facility is using for monthly medication reviews are not in the resident medical records and the pharmacist recommendation dated 7/16/21 was not addressed in the medical record. Additionally, the facility's policy and procedures for the Monthly Medication review stated The facility will develop and maintain policies and procedures for monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident She was informed that the policy did not identify the steps the pharmacist must take when an irregularity is identified that requires urgent action to protect the resident. 2) Resident #56's medical record was reviewed for medication review on 11/23/21 at 2:18 PM. Monthly medication reviews are not documented in the resident's medical record. Review of the monthly medication reviews revealed that Resident #56's name was not on the August list of residents without any recommendations. A request was made to the DON to provide the pharmacist identified irregularity from August 2021. On 11/24/21 at 9:00 AM the DON provided the Note to Attending Physician/Prescriber dated 8/14/21 this form was not in the resident medical record. The pharmacist indicated, The resident has a PRN order for [MEDICATION(S)] that has not been used in over 30 days. Please evaluate and consider discontinuing the above PRN at this time due to non-use. The form presented was signed by a Nurse Practitioner on 8/15/21 with her comment of will discontinue, pt (patient) stable Review of the current medication orders for November 2021 revealed that the medication in question was discontinued on 11/19/21 by the resident's attending physician. The Nurse Practitioner (staff #24) was interviewed at 10:35 AM on 11/24/21. She indicated that she receives a batch stack of pharmacy medication reviews and signs them. She acknowledged that she must have missed this one and did not discontinue the medication as she implied on the review from 8/14/21. She indicated that she would have to complete them and place them into the chart when she signs them. The concerns were reviewed with the Nursing Home Administrator and Director of Nursing at 4:45 PM on 11/24/21. The facility had not provided any additional information regarding the facility's monthly medication review policy and procedures. 3) On 11/17/21 at 2:53 PM a record review was conducted for Resident # 52. The resident has a history of depression and is being seen by behavior health. She/he was last seen on 10/6/21. Resident # 52 is taking [MEDICATION(S)] 15 mg 1 tab at bedtime, and [MEDICATION(S)] 10 mg every morning and at bedtime. The last pharmacy review was done on Aug.1, 2021, through 10/21/21. There were no recommendations and 3/1/21 through 6/12/21 no recommendations. There were no pharmacy reviews for July 2021, [DATE], and [DATE]. The Resident was out of the facility from 8/19/21 through 8/26/21 and 10/15/21 through 10/20/21.

Based on medical record review and interview it was determined that the facility failed to ensure that medical records were kept in accordance with the professional standards of practice as evidenced by: 1) failure to ensure that orders for CPR were discontinued in the electronic health record when a new MOLST was initiated and new orders for No CPR were instituted; 2) failure to ensure that the advanced directives that were referenced in MOLST forms were kept in the medical record; 3a & 3b) the failure to ensure that old (expired) Maryland Medical Orders for Life-Sustaining Treatment (MOLST) forms were voided when a new MOLST form was initiated; 4a & 4b) residents' immunization consent forms that were obtained without signature and date, and 5) nursing staff documented Foley catheter care for a resident that did not have a catheter. This was evident in 7 (#29, #174, #15, #6, #14, #60, and #173) out of 46 residents reviewed during the survey. The findings include: 1) On [DATE] review of Resident #174's medical record revealed a MOLST dated [DATE] for No CPR. Review of the electronic health record revealed current active orders for both Attempt CPR and No CPR. Review of the paper chart revealed a print out of the resident's orders which included both of these current active orders and was signed by the physician (MD #8) on [DATE]. On [DATE] at 2:17 PM the surveyor reviewed the concern with the Director of Nursing (DON) that there were two conflicting orders regarding CPR found in the medical record. The DON reported that the older order should have been taken out when the new order was put in place. 2) On [DATE] review of Resident #15's medical record revealed a MOLST form that was completed on [DATE] by the Nurse Practitioner (NP #24). Review of the MOLST revealed documentation that it had been discussed with the patient's health care agent as named in the patient's advance directive. On [DATE]further review of the medical record failed to reveal documentation of the resident's advance directive. At 12:51 PM the Director of Nursing (DON) was made aware that the advance directives were not found in the medical record. The DON reported that social work had them. At 2:54 PM the DON confirmed that they did not have a copy of the advance directive. Further review of the medical record failed to reveal documentation to indicate that social services had attempted to obtian the advance directives. On [DATE] at 7:50 AM the Social Service Director (SSD #7) reported that she had requested the advance directive from the family. Review of the electronic health record, including the [DATE] care plan meeting note, with the SSD #7 failed to reveal documentation regarding this request. On [DATE] at 8:03 AM the SSD #7 provided a copy of a hand written note, on a plain white sheet of paper, that was dated [DATE]. Review of this note revealed that it was regarding the [DATE] care plan meeting and did include documentation that the Advance Directives were requested and indicated the family member would send them. This documentation was more than 6 months after the resident had been admitted to the faciltiy. On [DATE]at 10:33 AM NP #24 confirmed that she had not actually looked at the advance directive when she completed the MOLST and indicated that she should have chosen the surrogate at that time. Later, on [DATE], the facility provided a copy of the resident's advance directive for the surveyor to review. On [DATE] at 2:50 PM the surveyor reviewed the concern with the DON regarding the failure to obtain the advance directives as referenced in the MOLST. 3a )Review of Resident #29's medical record on [DATE] revealed the resident has resided at the facility for more than a year, was cognitively intact and able to make their needs and wishes known. On [DATE] review of the paper chart revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form dated [DATE]. The MOLST (Maryland Medical Orders for Life-Sustaining Treatment) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options. On [DATE] review of the electronic health record confirmed the order for No CPR Option A-2 was in place. Review of the facility's policy for Advance Directives, with a revision date of [DATE], revealed: 3. The facility has defined advance directives as preferences regarding treatment options and are included, but not limited to: i. Maryland MOLST FORM.; and 7. Copies of changes or revocations of an advanced directive must be filed in the resident's medical record. The care plan team will be informed of such changes so that appropriate adjustments are made in the resident assessment. Minimum Data Set (MDS), and care plan. Prior advanced directives that have been changed are marked 'Voided' and retained in the medical record. On [DATE] further review of the paper chart revealed another MOLST form, dated [DATE]. This MOLST included orders to Attempt CPR. This MOLST had not been voided when the new MOLST was put in place. As such it was still a current active order. On [DATE] at 12:26 PM the surveyor reviewed with SSD #7 that another active MOLST order was found in the chart with conflicting order for CPR. The SSD #7 acknowledged the concern that the other MOLST was not voided, and immediately indicated that she would go speak with the resident to confirm the resident's wishes. Further review of the medical record and report from SSD #7 revealed that the [DATE] MOLST had been completed while the resident was in the hospital. On [DATE] at 1:02 PM the surveyor reviewed the concern with the Director of Nursing (DON) that multiple copies of the old MOLST were found on the chart and this poses a risk of the wrong MOLST being sent out with the resident if sent out via emergency medical services. The DON reported that staff would make a copy of the most recent MOLST. Also, reported that the physician here would of voided out the old MOLST. On [DATE] at 2:50 PM the surveyor reviewed the concern with the DON regarding the failure to ensure that old MOLST forms were voided. 3b) On [DATE] 12:27 PM, a record review of Resident #14's paper chart revealed a MOLST form dated [DATE] located at the beginning of the Resident's paper chart, and a MOLST dated [DATE] was located in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Further review revealed the MOLST dated [DATE] included orders for No CPR Option A-2, Do Not Intubate (DNI): Comprehensive efforts may include limited ventilator support by [CONDITION(S)] or [CONDITION(S)], but do not intubate. However, the MOLST dated [DATE] included additional orders to not attempt CPR if cardiac and pulmonary arrest occur, allow death to occur naturally. An interview was conducted with the Director of Nursing (DON) on [DATE] at 12:36 PM. She verified that there were 2 different MOLST forms in Resident #14's paper chart with the surveyor. The DON stated the recent MOLST (dated [DATE]) was saved in the wrong place, and the physician should have voided the [DATE] MOLST form. (Cross-reference F578) 4a) On [DATE] at 12:58 PM, a medical record review of Resident #6 was conducted. A Pneumococcal Immunization Informed Consent review revealed that verbal consent was obtained by Resident #6's responsible party (RP). However, the consent did not contain the date when the verbal consent was given. Further review of Resident #6's Influenza Vaccination Informed Consent indicated a verbal consent was obtained, however, the consent form did not include the date. 4b) On [DATE] at 1:05 PM, Resident #60's medical record was reviewed. A Pneumococcal Immunization Informed Consent review revealed that the consent contained Resident #60's name and reason for refusing as 'already given.' However, the consent did not include a signature of the Resident or date of refusal. During an interview with the Assistant Director of Nursing (ADON) on [DATE] at 1:10 PM, the ADON was made aware of those incomplete consent forms. (Cross-reference F 883) 5) A review of Resident #173's medical record was conducted on [DATE] at 11:19 AM. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #173's medical record revealed that during the resident's Urology consult visit on [DATE] an order was given by the Urologist to have the 'Foley removed at 6 AM on Monday [DATE]'. A review of Resident #173's progress note revealed the Foley catheter was removed on [DATE] at 5:05 AM. However, review of the Resident's Treatment Administration Record (TAR) revealed that the nursing staff documented that Foley catheter care was done from [DATE] to [DATE]. During an interview on [DATE] at 11:37 AM with the Resident's nurse (Staff #25), he stated that Resident #173 had a Foley catheter. He documented the care and monitoring ordered by the Resident's Physician in the TAR. However, at 11:39 AM on [DATE], the surveyor observed Staff #25 as he assessed Resident #173 and confirmed that the resident did not have a catheter. On [DATE] at 3:30 PM, Staff #25 stated that they did not assess Resident#173 before he documented that the Foley care and monitoring were completed in the TAR. (Cross-reference F658)

Based on observation, record review, and staff interview, it was determined that the facility failed to maintain strict infection control processes evidenced by: 1) failure to clean reusable medical equipment from resident to resident. This was observed as 2 of 2 staff performed vital sign checks on the long-term care unit, and 2) failure to implement appropriate standard precautions to help prevent the spread of infections. This was found to be true for 1 of 4 nurses observed during the medication administration facility task. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. Standard precautions are the minimum infection prevention and control practices that must always be used for all patients/residents in all situations. Transmission-based precautions are used when standard precautions alone are not enough to prevent the spread of an infectious agent. The findings include: 1) On 11/18/21 at 8:45 AM, Geriatric Nursing Assistant (GNA) Staff #19 was observed using the same blood pressure cuff and Oxygen monitor from resident in room N14 B to resident in room N 15 B without cleaning. During an interview with Staff #19 on 11/18/21 at 8:48 AM, the staff confirmed thatb she did not perform cleaning prior to using the same medical equipment to the other resident. Also, Staff #19 stated she did not know about the cleaning equipment. On 11/19/21 at 7:57 AM, surveyor saw GNA (staff #15) use a blood pressure reading device on the residents in room N11. Using the same device. The GNA checked the 1st resident's blood pressure and then checked their roommate's blood pressure without sanitizing the device and was immediately interviewed. During the interview, the staff confirmed that it was not expected for her to clean the device between residents. An interview and record review were conducted with the Assistant Nursing Home Administrator (ADON) on 11/23/21 at 9:30 AM. Surveyors shared with her the review of the facility's Standard Precautions policy that stated, 'Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed, and single-use items are properly discarded. 2) The surveyor observed RN#9 during morning medication administration on 11/18/21 from 8:00 AM to 9:30 AM as part of the facility's medication administration observation necessary for the facility's annual survey. The surveyor observed RN#9 repeatedly fail to use hand hygiene between patient assessments and medication administration. The surveyor expressed concerns to RN#9 that he/she failed to use hand hygiene when he/she visited patient rooms and when he/she prepared medications for administration. RN#9 stated that he/she was busy and did not notice that he/she failed to perform the correct hand hygiene between visiting patient rooms and medication administration. The Administrator and Director of Nursing was notified of the surveyor's concerns during a meeting on 11/24/21 at 4:50 PM.

Based on medical record review and interview it was determined that the facility failed to have an effective system in place to ensure resident's who were capable to make their own decisions were involved in decisions regarding life sustaining treatment orders; and failed to ensure that a copy of a resident's advance directive was kept in the resident's medical record. This was found to be evident for 3(Resident #29, #15 and #14 ) out of 7 residents reviewed for Advance Directives during the survey. The findings include: 1) Review of Resident #29's medical record on [DATE] revealed the resident has resided at the facility for more than a year, was cognitively intact and able to make their needs and wishes known. On [DATE] review of the paper chart revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE]. The MOLST (Maryland Medical Orders for Life-Sustaining Treatment) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life sustaining treatment options. This form includes a section for the practitioner to certify that these orders are entered as a result of a discussion with and the informed consent of , there is then an area to check off if the discussion was with the patient, or the health care agent, or a court appointed guardian, or the patient's surrogate as per the authority granted by the Health Care Decisions Act. Further review of the MOLST dated [DATE] revealed the practitioner indicated there had been a discussion with the patient's surrogate. No documentation was found to indicate these orders had been reviewed with the resident. The MOLST included orders for No CPR Option A: Comprehensive Efforts to Prevent Arrest: Prior to arrest, administer all medications needed to stabilize the patient. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. Option A-2, Do Not Intubate (DNI): Comprehensive efforts may include limited ventilatory support by [CONDITION(S)] or [CONDITION(S)], but do not intubate. On [DATE] review of the electronic health record confirmed the order for No CPR Option A-2 was in place. Further review of the medical record revealed a current care plan, with an initiation date of [DATE] for I have selected a full code status. A full code would indicate a resident wanted to have CPR performed if needed. The first intervention listed in this care plan is Check with me quarterly to see if I've changed anything. Review of the facility's policy for Advance Directives, with a revision date of [DATE], revealed: 3. The facility has defined advance directives as preferences regarding treatment options and are included, but not limited to: i. Maryland MOLST FORM.; and 6. The care plan team at a minimum will review annually/or as needed with the resident his/her advance directives to ensure that they are still the wishes of the resident/patient. Such reviews will be made during the annual assessment process and recorded on the resident assessment instrument (MDS) and as needed. Advanced Directives will also be reviewed when there is a change in condition, during the quarterly care plan meeting or when asked to be reviewed by the resident and/or responsible party. Further review of the medical record revealed the resident had an annual Minimum Data Set (MDS) assessment completed [DATE] and quarterly assessments completed [DATE] and [DATE]. The expectation is that a care plan meeting, which would include the resident, occurs after each of these assessments. On [DATE] at 11:46 AM the Social Service Director (SSD #7) reported that she does confirm residents' code status during care plan meetings, however, she went on to report that the Social Service Assistant (SSA #11) facilitates Resident #29's care plan meetings. On [DATE] at 11:55 AM the SSA #11 confirmed that she facilitates the care plan meetings for the long term care residents. She confirmed that she does not review the items in the care plan. When asked if she reviews the code status, SSA #11 indicated if there was a question about the status, for example if the physician or family indicated they wanted to change the status, then she would review the code status. In a follow up interview at 12:15 PM the SSA #11 confirmed that the resident was his/her own responsible party. She also provided documentation that a care plan meeting had occurred in April, but confirmed no care plan meeting since then. SSA #11 again confirmed that she does not write or review the care plans, stating that the SSD #7 reviews the care plans. Further review of the paper chart revealed another MOLST form, dated [DATE], that indicated it had been completed based on a discussion with the patient and the patient's health care agent as named in the patient's advance directive. This MOLST included orders to Attempt CPR. This MOLST had not been voided when the new MOLST was put in place. As such it was still a current active order. On [DATE] at 12:26 PM follow up interview with SSD #7 who confirmed she does review the resident's care plans. Surveyor requested SSD #7 review the residents current MOLST (the one dated [DATE]) and asked if there was anything of concern. SSD #7 identified that the MOLST was for a DNR, had been completed with a surrogate, and also identified that it had been completed when the resident was in the hospital. Surveyor also reviewed with SSD #7 that another active MOLST order was found in the chart with conflicting order for CPR, as well as the care plan which still indicates the resident wishes to be a full code. The SSD #7 acknowledged the concern that the other MOLST was not voided, and immediately indicated she would go speak with the resident to confirm the resident's wishes. On [DATE] at 12:50 PM the SSD #7 presented with a Health Care Decision Making Worksheet signed by herself and the resident. Review of this worksheet revealed the resident wishes to be a No CPR, Option B, Palliative and Supportive Care. SSD #7 reported she will have the Nurse Practitioner complete a new MOLST form with the resident. On [DATE] at 2:07 PM Director of Nursing reported, in regard to the two conflicting MOLST forms, we can't void it out unless they discontinue the old MOLST; we wouldn't void it without an order; that was a unique situation. On [DATE] further review of the medical record revealed a MOLST, dated [DATE], which had been discussed with the resident and included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use [CONDITION(S)] or [CONDITION(S)]. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally. On [DATE] at 8:17 AM surveyor reviewed the concern with SSD #7 that the first item in the care plan regarding code status was to review it with the resident quarterly to see if anything changed. SSD #7 confirmed that this had not been reviewed at the care plan meeting that had occurred. On [DATE] at 2:50 PM surveyor reviewed the concerns with the Director of Nursing regarding the failure to include the resident in the MOLST completion, as well as, having two active conflicting MOLST forms on the chart. 2) On [DATE] review of Resident #15's medical record revealed a MOLST form that was completed on [DATE] by the Nurse Practitioner (NP #24). Review of MOLST revealed documentation that it had been discussed with the patient's health care agent as named in the patient's advance directive. On [DATE] further review of the medical record failed to reveal documentation of the resident's advance directive. At 12:51 PM the Director of Nursing (DON) was made aware that the advance directives were not found in the medical record. The DON reported that social work has them. At 2:54 PM the DON confirmed that they did not have a copy of the advance directive. Further review of the medical record failed to reveal documentation to indicate social services had attempted to obtain the advance directives. If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents must be obtained and maintained in the same section of the resident's medical record readily retrievable by any facility staff. On [DATE] at 7:50 AM the Social Service Director (SSD #7) reported that she had requested the advance directive from the family. Review of the electronic health record with the SSD #7, including the [DATE] care plan meeting note, failed to reveal documentation regarding this request. On [DATE] at 8:03 AM the SSD #7 provided a copy of a hand written note, on a plain white sheet of paper, that was dated [DATE]. Review of this note revealed it was in regard to the [DATE] care plan meeting and did include documentation that the Advance Directives were requested and indicated the family member would send them. This documentation was more than 6 months after the resident had been admitted to the faciltiy. On [DATE]at 10:33 AM, the NP #24 confirmed that she had not actually looked at the advance directive when she completed the MOLST and indicated she should of chosen surrogate at that time. Later, on [DATE], the faciltiy provided a copy of the resident's advance directive for surveyor review. On [DATE] at 2:50 PM surveyor reviewed the concern with the DON regarding the failure to obtain the advance directives as referenced in the MOLST. 2) On [DATE] 12:27 PM review of Resident #14's paper chart revealed two different MOLST in the resident's paper chart: a MOLST dated [DATE] placed at the beginning of the resident's paper chart, and a MOLST dated [DATE] placed in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The MOLST dated [DATE] included orders for: 1) No CPR Option A-2, Do Not Intubate (DNI): Comprehensive efforts may include limited ventilator support by [CONDITION(S)] or [CONDITION(S)], but do not intubate, 2) may use only [CONDITION(S)] or [CONDITION(S)] for artificial ventilation, as medically indicated, 3) may give any blood product (whole blood, packed red blood cells, plasma or platelets) that is medically indicated, 4) transfer to hospital for any situation requiring hospital-level care, 5) medical workup- blank, 6) may use antibiotics (oral, intravenous or intramuscular) as medically indicated, 7) may give fluids for artificial hydration as a therapeutic trial, but do not give artificially administered nutrition, and 8) do not provide acute or chronic [CONDITION(S)]. However, the MOLST dated [DATE] included orders for: 1) No CPR, Option B, Palliative and Supportive Care: prior to arrest, provide passive oxygen for comfort and control any external bleeding. Prior to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use [CONDITION(S)] or [CONDITION(S)]. If cardiac and/or pulmonary arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally, 2) do not use any artificial ventilation (no intubation, [CONDITION(S)], or [CONDITION(S)]), 3) do not give any blood products, 4) transfer to hospital for severe pain or severe symptoms that cannot be controlled otherwise, 5) only perform limited medical tests necessary for symptomatic treatment or comfort, 6) may use oral antibiotics only when indicated for symptom relief or comfort, 7) do not provide artificially administered fluids or nutrition, and 8) do no provide acute or chronic [CONDITION(S)]. On [DATE] at 12:30 PM review of the electronic health record confirmed the order for No CPR Option B, Palliative and supportive care was in place. On [DATE] at 12:36 PM, the Director of Nursing (DON) confirmed two different MOLST were filed in Resident #14's paper chart. The DON stated the recent MOLST (dated [DATE]) saved the wrong place, and the Physician should void the old MOLST form. Also, the DON added, I will ask the Medical Director to talk to you. There was no additional discussion held with the Medical Director and surveyor team. The facility Administrator and the DON were made aware of the above concerns on [DATE] at 5:00 PM.

Based on medical record review and interview, the facility failed to notify a resident's responsible party and provider when the resident received a injury that required treatment (Resident #226). This was evident for 1 out of 2 residents reviewed during an annual survey for neglect. The findings include: Review of Resident #226's medical record revealed the resident was admitted to the facility on [DATE] for rehabilitation after a hospital stay for a weakened state. Documentation dated 5/16/2021 at 7:59 PM revealed a Registered Nurse (RN) observed a treated arm wound for the resident that was not ordered by the provider. The documentation stated that the RN notified the Administrator, Director of Nursing, the on-call provider, and the family representative about the un-ordered arm wound treatment. An order was obtained by the provider to properly treat the arm wound. During an interview with the Director of Nursing (DON) on 11/23/2021 at 1:00 PM revealed that the DON was unaware of the arm wound incident in May 2021. The DON stated that he/she was not DON at the time of the incident. The DON consulted the resident's medical record and confirmed that the resident was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator was made aware of the surveyor's concerns on 11/24/21 at 4:40 P.M.

Based on medical record review, staff interview, and review of administrative records, it was determined that the facility failed to provide written notification to residents or resident representative when the facility determined that a resident no longer qualified for Medicare part A skilled services. This is identified for 1 (Residents #124) of 2 residents reviewed that remained in the facility after termination of Medicare part A skilled services. The findings include: Notification to residents regarding the end of their Medicare coverage is required to be minimally 48 hours prior to the scheduled effective date that coverage will end, therefore, affording them an opportunity to appeal the decision or to prepare for discharge. In addition, CMS is very specific in the form that is required to be used for the notification of the non-coverage of Medicare services. The SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage) provides information to residents/beneficiaries that services may no longer be covered by Medicare and addresses the resident's liability for payment should they wish to continue receiving the skilled services. The NOMNC (Notice of Medicare Non-coverage) informs the beneficiary of his or her right to file an appeal of the decision and right to an expedited review of Medicare non-coverage of services. At the initiation of the survey on 11/15/21, the facility was requested to provide a list of Medicare beneficiaries who were discharged from a Medicare-covered Part A stay with benefit days remaining in the past 6 months prior to the survey. From the list, three residents were randomly selected for review. On 11/17/21 the Social Worker (staff #7) was given the SNF [skilled nursing facility] Beneficiary Protection Notification Review forms to be filled out for 2 residents that had remained in the building after the last covered day of Medicare part A, and 1 for a resident that had discharged from the facility. The Social Worker returned the forms on 11/18/21. Upon review of the forms, there was no evidence/indication that Resident #124 or the resident ' s representative was informed in writing of the change in payor source. Review of the SNF Beneficiary Protection Notification Review form for Resident #124 revealed that Resident #124 started skilled service on 7/28/21 and ended on 7/30/21, and a 2nd skilled start date of 8/4/21 with a last covered Medicare part A date of 8/10/21. The Social Worker indicated on the Review form that notifications were not provided to the resident's representative. The Social Worker Staff #7 was interviewed on 11/19/21 at 2:10 PM. She indicated that she thought that telephonic communication was an acceptable way of informing the resident or the resident representative of a change in payor source. There was not any indication that Resident #124 ' s representative was mailed a copy of the SNFABN form or the NOMNC form upon telephonic communication. The fact that the facility was not informing residents or resident representatives in writing was reviewed with the Nursing Home Administrator and the Director of Nursing during the exit conference held at 5:45 PM on 11/24/21.

Based on resident and staff interviews and review of medical records, it was determined that facility staff failed to ensure that an effective process was developed and implemented to reach an on call physician or practitioner resulting in failure to obtain pain medication timely for a newly admitted surgical resident for one (Resident # 158) of 24 residents in the Stage two sample. The findings include: During Stage 1 of the survey, on [DATE], at 1:30 PM, Resident # 158 told the surveyor that he/she was upset because on admission the facility staff did not provide pain medication to the resident after back surgery. He/she stated that he/she arrived at about 8:00 PM and did not receive any pain medication until 9:00 AM the next day. Medical record review, conducted during Stage two of the survey on [DATE] and 9, 2017, revealed the following: Resident # 158 was admitted to the facility at 7:35 PM following surgery. The hospital discharge summary listed transfer medications including pain medications [MEDICATION NAME] ,[DATE], one every four hours, and [MEDICATION NAME], 500 mg, 1 tablet 2 times per day as needed for pain. Facility staff use Emedicall, an electronic system to contact physicians or other providers after hours. An electronic message, using this system, was sent from the facility by the evening nurse supervisor at 8:39 PM the evening of admission to the on call nurse practitioner stated, We did not receive a prescription for [MEDICATION NAME], can you please fax a script to the pharmacy or we can fax you a filled in script. Interview of the nurse supervisor (employee # 1) on [DATE], at 1:00 PM revealed that she is responsible for ordering the medications for residents. She stated that the nurse taking care of Resident # 158 should have let her know the severity of the pain. She also stated that the only method for reaching the on call physician was through the Emedicall system. At 11:18 PM, the initial nursing assessment stated that the patient complained of back pain and medication pending at this time. An electronic message, sent from the facility nurse at 8:39 PM the evening of admission to the on call nurse practitioner stated, We did not receive a prescription for [MEDICATION NAME], can you please fax a script to the pharmacy or we can fax you a filled in script. The morning following admission, at 12:27 AM, a second electronic message, labeled Escalation Phone Call, Emergency was sent to the on call physician, who took over call duty at 9:00 PM, stating that the resident was complaining of severe back pain and requested that the on call nurse practitioner call the pharmacy for a verbal order. At 5:00 AM, a note on the Medication Administration Record [REDACTED]. At 7:00 AM, a note on the MAR indicated [REDACTED]. At 5:23 AM, a nurse's note stated, complaint of severe pain. Pain pill not available A narrative note at that time stated, Patient refused his vital signs because he is frustrated not to have his pain pill. At 7:42 AM, a third electronic message, labeled Escalation Phone Call was sent to the on call physician stating Resident is a new admit. Complaint of severe back pain. No script was sent from the hospital. On [MEDICATION NAME] ,[DATE] mg, one tablet every four hours as needed for pain. Could you please call the pharmacy in for a verbal order . A written statement provided to the Medical Director and the surveyor on [DATE] at 1:04 PM indicated that on the night of the resident's admission, the on call physician (employee # 2) had record of one Emedicall at 12:27 AM that was expired (meaning no response from the physician). He/she stated that he/she may have missed that call or slept through the page and that there were no further calls that night regarding this patient. He/she further stated that Typically, if a page is not responded to the caller will call our office and the operator will attempt to call the physician. Interview of the Medical Director and Director of Nursing at 10:00 AM on [DATE] revealed that the phone number for contacting the on call physician group has since been provided to nursing staff, but was not available to them at the time that Resident # 158 was admitted . During an interview of the Director of Nursing at 9:00 AM on [DATE], she stated that the on call physician did not respond to requests for pain medication on the night of admission. She further stated that nursing staff should have called the facility's Medical Director or sent the resident back to the hospital. Interview of the Charge Nurse on [DATE] revealed that the Nurse Practitioner (employee # 3) for the facility came in at about 8:00 AM and approved the orders for the resident's medications. Review of the Medication Administration Record [REDACTED]. A nurse's note recorded at 10:11 AM the morning following admission indicated that the resident was seeking to go home and had suicidal ideation. An emergency psychiatric evaluation was requested and approved by the Nurse Practitioner. At around 10:00 AM, according to an interview with the Charge Nurse, the Medical Director for the facility came in and completed an initial examination and interview of the resident. Interview of the Medical Director at 10:00 AM on [DATE] revealed that when he examined the resident, he was not deemed to be suicidal. The Medical Director stated that he believed the suicidal ideation was caused by the resident's pain and that once the pain medicine was administered the resident was feeling better. The psychiatric evaluation, provided two days later, indicated that the resident felt depressed for the past 6- 8 months due to worsening pain and mobility issues. The evaluation further stated that the resident was angry at staff because on the day that his pain medications weren't in, he wanted staff to tell him, more specifically, when they would arrive.

Based on medical record review and interview of facility staff it was determined that the facility staff failed to provide appropriate care and treatment to prevent pressure sores and failed to provide appropriate care and treatment to prevent a pressure sore from worsening. This was evident for 1 of 2 sampled residents selected for review. The findings include: Resident #1 was an [AGE] year old with a [DIAGNOSES REDACTED]. The resident's medical record was reviewed on 2/15/2013 and 2/26/2013. Additional information was provided by the facility on 3/4/13 and 3/6/13. Review of the resident's Minimum Data Set (MDS), an assessment tool, dated 10/10/12 revealed that the resident was totally dependent on facility staff for activities of daily living, including bed mobility. Additionally, the resident was incontinent of bowel and bladder and was at high risk for the development of pressure sores. Review of the resident's care plan revealed that interventions had been initiated for turning and positioning every 2 hours. Review of the physician's orders [REDACTED]. Review of the resident's treatment administration record (TAR) and nursing progress notes 11/1/2012 through 11/19/2012 revealed that there is no documented evidence that the resident was turned and positioned every 2 hours and no documented evidence that [MEDICATION NAME] Cream was applied every shift with perineal care. Additionally, review of the physician's orders [REDACTED]. On 11/20/2012 the resident was evaluated by the wound care physician. The wound care physician documented that the resident had a new lesion in the intergluteal fold (sacrum) which measured 2.5 cm x 0.3 cm x 0.1 cm. The wound was 10% yellow slough and 90% granulation tissue. The wound care physician performed [MEDICATION NAME] debridement of the wound and recommended treatment to the wound with Maxsorb to the wound every other day and [MEDICATION NAME] cream around the Maxsorb every shift. Additionally, the wound care physician recommended aggressive offloading of the area at all times. Review of the Physician order [REDACTED]. The physician failed to give orders to offload pressure to the resident's sacral area. Review of the treatment administration record (TAR) revealed that the treatment to the sacral wound was administered as ordered. Further review of the TAR and review of the nursing progress notes revealed that there is no documented evidence that nursing implemented interventions for a turning and positioning schedule to offload pressure to the resident's sacral area. Additionally, the facility staff failed to update the resident's care plan to reflect interventions related to the resident's sacral wound. On 11/27/2012 the resident was evaluated by the wound care physician. The wound care physician documented that the resident had a lesion in the intergluteal fold (sacrum) which measured 2.7 cm x 0.8 cm x 0.1 cm. The wound was 80% black necrotic tissue and 20% granulation tissue. The resident's sacral wound had deteriorated as evidenced by an increase in the size of the wound and the presence of 80% black necrotic tissue. The wound care physician recommended treatment to the wound with Santyl on the wound and [MEDICATION NAME] Cream around the wound. Additionally, the wound care physician recommended aggressive offloading of the area at all times. On 11/27/2012 the nurse documented in the nursing progress note that the resident's attending physician was notified of the wound care physician's recommendations and approved an order for [REDACTED]. The nurse failed to transcribe the physician's orders [REDACTED]. Additionally, there is no documented evidence that the nurse implemented interventions for a turning and positioning schedule to offload pressure to the resident's sacral wound. The facility staff failed to update the resident's care plan to reflect interventions related to the resident's sacral wound. On 12/2/2012 an entry was made on the TAR for the treatment to the resident's sacral wound with Santyl every day. This was 5 days after the resident's attending physician approved an order for [REDACTED]. On 12/4/2012 the resident was evaluated by the wound care physician. The wound care physician documented that the resident now had a stage 4 sacral pressure sore which measured 3.0 cm x 2.0 cm x 2.5 cm. The wound was 80% black necrotic tissue and 20% granulation tissue. The resident's sacral wound had further deteriorated as evidenced by an increase in the size of the wound. The wound care physician performed sharp debridement of the resident's sacral wound and recommended packing the wound with Iodosorb and gauze. The wound care physician further recommended aggressive offloading of the area and an air mattress. On 12/4/12 the physician gave orders to pack the resident's sacral wound with [MEDICATION NAME] and cover with gauze every day. The physician also ordered an air mattress at all times. The physician failed to give an order to offload pressure to the resident's sacral wound. Additionally, there is no documented evidence that the nurse implemented interventions for a turning and positioning schedule to offload pressure to the resident's sacral wound. The facility staff failed to update the resident's care plan to reflect interventions related to the resident's sacral wound. Review of the TAR revealed that on 12/7/12 the nurse implemented interventions to turn and position the resident every 2 hours. On 12/11/12 a care plan was initiated related to the resident's sacral pressure sore.