Every finding on record at Fahrney-Keedy Memorial Home

Based on interviews and review of pertinent documentation, it was determined that the facility failed to ensure a full-time, qualified dietetic service supervisor to oversee food preparation and daily kitchen operations. This had the potential to affect all residents.The findings include: On 3/25/26 at 12:25 PM, the Director of Culinary Services (Staff #3) was interviewed. During the interview, he reported that he was not certified as a dietary manager (CDM). Staff #3 stated that he received consultation from a regional CDM (Staff #7). Staff #3 reported that consultation from CDM Staff #, occurred about once a month, and sometimes more frequently.On 03/25/2026 at 12:45 PM, The Director of Nursing (DON) was interviewed. She reported that she was not aware of Director of Culinary Services (Staff #3) qualifications and stated that the Director of Culinary Services (Staff #3) is an employee of the company, contracted to provide specialized culinary and support services to the facility. The DON reported that the regional Certified Dietary Manger (Staff #7) had not worked for the contracted culinary service company for about six months and could not have been providing consultation for the past six months to the Director of Culinary Services (Staff #3). The DON further reported that the contracted company provides a Registered Dietitian (RD) who works at the facility every Friday and provides education and oversight to the Director of Culinary Services (Staff #3). The surveyor requested documentation that the RD provided education documentation and evidence of oversight for the Kitchen operations.On 3/25/26 at 3:00 PM, the DON provided the requested documentation. Review of the documentation with the DON revealed three In-Services were conducted for the kitchen staff in July 2025. Furter review revealed that the Training Facilitators documented on the sign-in sheet were the Director of Culinary Services (Staff #3) and the Manager of Culinary Production (Staff #5) . No other instructors were listed on the document. The DON confirmed that the Manager of Culinary Production was also not a certified dietary manager.On 3/26/26 at 9:10 AM, the Administrator was interviewed. The Administrator reported that the Director of Culinary Services (Staff #3) had the required experience, education, and was provided with professional consultation. The Administrator and surveyor reviewed the Director of Culinary Services (Staff #3) educational documentation. Review of these documents revealed a Certified ServSafe Instructor and Registered ServSafe Examination [NAME] certification that expired on 5/11/23, as well as a second ServSafe certification that expired on 2/12/24. Prior to the end of the survey, the Administrator failed to provide credible evidence that the contracted Registered Dietician provided oversight, consultation, or education to the facility's current kitchen staff and consultation from a certified dietary manager.On 3/26/26 at 10:30 AM during an interview with the Administrator, he confirmed that the facility was unable to provide documents proving the Director of Culinary Services (Staff #3) had current professional certifications or evidence of consultations from a qualified Certified Dietary Manager or Registered Dietician or Certified Dietary Manager.

Based on observation, record review, and staff interview, it was determined that the facility failed to ensure that residents received physician-ordered treatments and medications. This deficient practice was identified for 1 (Resident #44) of 1 resident reviewed for general skin conditions and 1(Resident #9) of 1 resident reviewed for pain management.Findings include:1). Resident #44 has a medical history that includes, but is not limited to, chronic pain, anxiety, depression, respiratory failure, diabetes, cerebrovascular accident (stroke), and a history of self-inflicted skin injuries related to scratching.On 3/23/26 at 12:30 PM, the surveyor observed Resident #44 lying in bed watching television with a bandage to the right arm and multiple sores on the forehead and scalp.On 3/24/26 at 11:02 AM, review of a skin assessment dated [DATE] revealed multiple areas of impaired skin integrity, including rashes, lesions, scratches, and bruising affecting the head, chest, shoulders, axilla, and bilateral upper extremities.On 3/24/26 at 11:32 AM, review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that on 3/8/26, the following physician-ordered treatments and interventions were not documented as completed:-Cleanse right shoulder wound with normal saline, apply hydrogel with silver to wound bed, and cover with foam dressing (daily, day shift) -Cleanse right neck/shoulder wound with normal saline, apply topical antibiotic ointment (TAO), and apply dry dressing (daily, day shift) -Apply Tacrolimus 0.1% topical cream to bilateral upper extremities for itching/rash (day and evening shift) -Apply Voltaren (Diclofenac Sodium 1%) gel to right shoulder for pain management (day and evening shift) -Apply in-house nourishing skin cream to bilateral upper and lower extremities for skin integrity maintenance (twice daily, day and evening shift) -Apply barrier cream to perineal area and buttocks every shift and as needed after incontinence episodes -Toilet resident daily at 11:00 AM (day shift) -Ensure Roho cushion in wheelchair every shift -Ensure Dycem is in place on wheelchair and check placement every shift for fall prevention -Float heels while resident is in bed every shift for pressure relief -Apply heel elevation pillow while in bed and check placement every shift -Ensure non-skid socks are worn while in bed or recliner every shift -Maintain bilateral upper side rails while in bed as an enabler for mobility and transfers -Turn and reposition resident every hour while in wheelchair and every two hours while in bed for pressure relief -Maintain Enhanced Barrier Precautions for multidrug-resistant organism (MDRO) every shift On 3/24/26 at 12:37 PM, the surveyor interviewed the Director of Nursing (DON) regarding gaps in documentation and asked what it means when there is nothing documented. The DON stated, Someone didn't complete their charting. When asked specifically about 3/8/26, the DON reported that the facility had identified that an agency nurse (LPN #2) had been assigned several residents and failed to complete ordered treatments and care for a few of them. The DON stated that the issue was identified after being alerted to missing documentation and observing that Resident #44's dressing had not been changed as ordered. The DON confirmed that additional residents were affected and that the agency nurse was not permitted to return to the facility.2). Resident #9 has a history of chronic pain and other medical conditions. Record review confirmed that a care plan was developed which included treatments and medications intended to assist the resident in managing their specific medical conditions.On 3/24/26 at 1:37 PM, the surveyor reviewed Resident #9's Medication Administration Record (MAR) and Treatment Administration Record (TAR). The review identified that on 3/8/26, multiple ordered treatments and one medication were not documented as completed.The missing documentation included the following:-Clinical Monitoring for Pain: Every shift documentation indicating whether the resident had pain (Yes/No), with additional documentation if Yes. -TED Hose (knee-high): Apply in the morning and remove it in the evening (day shift). -Anti-Fungal Powder (in-house): Apply to left groin every day and evening shift for MASD (14-day course). -Acetaminophen 500 mg (2 tablets every 8 hours)-Nourishing Skin Cream (in-house): Apply to bilateral upper and lower extremities twice daily (day and evening shift). -Dignity Urinary Drain Bag Placement: Ensure proper placement every shift. -Heel Floating: Float heels while in bed every shift for pressure relief. -Barrier Cream (in-house): Apply to peri-area and buttocks every shift and as needed after each incontinence episode. -Enhanced Barrier Precautions: Maintain isolation precautions for suprapubic catheter every shift. -Suprapubic Catheter Care: Provide catheter care and check leg strap placement every shift per protocol. -Toileting Schedule: Toilet resident upon rising, before and after meals, and at bedtime every shift. -Repositioning: Turn and reposition every hour while in wheelchair and every two hours while in bed every shift. On 3/24/26 at 12:37 PM, the surveyor interviewed the Director of Nursing (DON) regarding the identified gaps in documentation. The DON explained that an agency nurse (LPN#2) was identified by the facility as not completing the duties assigned for Resident #9 and they placed her on a Do Not Return list (meaning she is not permitted to return to work at the facility).

Based on observations and interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: 1) An initial tour of the facility's kitchen was conducted on 1/27/25 at 8:40 AM with staff #4, food services manager. An observation of the kitchen's walk-in refrigerator revealed the following: -opened Greek yogurt, Pineapple juice, chicken base seasoning, Hungarian paprika seasoning, Dijon mustard sauce, Worcestershire sauce, and an opened lemon juice and cooking wine halfway used. The observation failed to show the items' open and use-by dates. Staff #4 said they should have been labeled with these dates. After the surveyor's intervention, staff #4 removed the items from the refrigerator to dispose of them. A continued observation of the refrigerator noted the following: -an opened [NAME] Italian dressing with a label that stated, prep date 12/27/24 and use by 1/25/25. - chopped garlic labeled prep date 12/27/24 and use by 12/29/24. -chicken broth with a label that stated, prep date 1/24/25 and use by 1/26/25. -cooked ground beef labeled with a prep date of 1/22/25 and use by 1/24/25. -cooked pasta labeled prep date 1/21/25 and use by 1/23/25. -cooked pork loin labeled prep date 12/24/24 and use by 1/26/25. -coleslaw labeled use by 1/22/25. -sliced fresh tomatoes labeled prep date 1/23/25 and use by 1/25/25. -leftover cabbage and carrots labeled prep date 1/23/25 and use by 1/25/25. Leftover cream of wheat labeled prep date 1/22/25 and use by 1/24/25. Staff stated that we usually don't keep leftover cream of wheat; it should have been disposed of. -leftover cooked turkey labeled prep date 1/23/25 and use by 1/25/25. -Two containers of diced cantaloupes labeled use by 1/18/25. -fresh diced parsley labeled prep date 1/16/25 and use by 1/18/25. Staff #4 said he would dispose of them immediately and added that they usually don't keep leftovers from some foods like cream of wheat but could not explain why they were still in the refrigerator. In an interview later that day, staff #4 indicated that the facility was changing its food labeling system to fix its food labeling challenges. 2) An observation of the kitchen staff preparing food and the residents' lunch food trays on 1/30/25 at 11:45 AM revealed the following concerns: a) Staff #5, a dietary aide, was observed picking up a tray with multiple plates containing food from the kitchen to the dining room. She served them to residents in the dining room, then picked up meal tickets from various tables. Staff #5 returned to the kitchen, put on gloves, and then picked up the phone in the kitchen. Staff #5 did not remove gloves or wash her hands and returned to pick up food from the tray line. Staff #4, the food services manager, was present and was immediately made aware. Staff #4 called out staff #5 to wash their hands before touching any food. Staff #4 then told the surveyor that he understood the concern about hand hygiene and would ensure hand sanitizers were available in the dining room for hand hygiene between servings. b) On 1/30/25 at 11:50 AM, staff #7, a dietary aide, was observed picking up the residents' food from the tray line to the meal carts. The observation failed to show that Resident #7 had a hair restraint (covering for the hair to prevent hair from contacting food). Staff #4 was immediately made aware. After the surveyor's intervention, staff #7 was noted with a hair net. c) An observation was made on 1/30/25 at 11:55 AM of staff #6 wearing gloves and dishing food at the tray line. Staff #6 stepped away from the tray line, touched a food warmer with the gloves, and opened it. He then returned to the tray line and touched bread with the same gloves. After the surveyor's intervention, staff #6 removed his gloves, washed his hands, and changed his gloves. Staff #4 said he did afternoon hurdles with the dietary staff and would go over hand hygiene in those sessions. He also added that his staff received hand hygiene training upon hire and yearly.

Based on observations, record reviews, and staff interviews, it was determined that the facility failed: to comply with isolation protocols, to have a prevention plan for Legionella, and staff failed to use appropriate personal protective equipment (PPE). This was evident for 3 (Resident #71, #85, #39) of 6 residents reviewed for infection control; and 1 of 1 plan reviewed for water management which has the potential to affect all residents. The findings include: 1) Resident #71 was diagnosis with pneumonia on 1/22/25 after chest x-ray confirmed it. On 1/27/25 at 9:11 AM the Assistant Director of Nursing (Staff #1) reported that Resident #71 is on droplet precautions, and will require gowning to enter the room. At 9:20 AM, in front of Resident #71's room, surveyor observed droplet precaution sign posted on outside of the room, the supplies were located on the door, and the door was open. Resident #71 was observed in a recliner chair in the room. Record review confirmed that Resident #71 was placed on Droplet precautions on 1/23/25 for 11 days by the Nurse Practitioner. According to the Centers for Disease Control and Prevention (CDC), health care personnel caring for residents on Droplet Precautions must wear a fit tested N-95 mask, a gown, and gloves for close patient contact, which is considered to be within six feet or less or in the room of the residents. Use Droplet Precautions for patients known or suspected to be infected with germs transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. On 1/28/25 at 9:08 AM Surveyor observed a Geriatric Nursing Assistant (GNA) #8 sitting in a chair in resident #71's room. GNA #8 was wearing a surgical mask but no other Personal Protective Equipment (PPE); no gown or N95. At 9:10 AM, an interview with the Director of Nursing (DON), confirmed Resident #71 was still on droplet precautions. Surveyor reviewed the concern with the DON about observed staff person in the room only wearing mask, and no gown. The DON indicated she would address the issue. On 1/29/25 at 11:51 AM, the surveyor interviewed GNA #8 who acknowledged that she went into Resident #71's room the day before and did not put on the appropriate Personal Protective Equipment (PPE). 2) According to the CDC, Legionella is a type of bacteria that causes Legionnaires' disease and Pontiac fever. Legionella grows best in large, complex water systems that are not adequately maintained. The bacteria can become a health concern when they grow and spread in human-made building water systems like: showerheads and sink faucets, hot tubs, decorative fountains and water features such as hot water tanks and heaters, large, complex plumbing systems, and cooling towers. On 1/29/25, the facility provide a copy of their Legionella Water Management Program policy, which was last revised in September 2022. Review of this policy revealed that the water management program would include a detailed description and diagram of the water system in the facility, and would identify areas in the water system that could encourage the growth and spread of Legionella and other waterborne bacteria. The program would be able to identify any situations that could lead to Legionella growth and specific measure to be used to control the introduction and/or spread of Legionella; the control limits or parameters that are acceptable and that are monitored. There would be a diagram of where control measures are applied; and a system to monitor control limits and effectiveness of control measures. The water management program was to be reviewed at least once a year or sooner if any of the following occur: the control limits are consistently not met; there a major maintenance of water service change; there are any disease cases associated with the water system; or there are changes in laws, regulations, standards or guidelines. Further record review revealed that there were no text or flow diagrams of the buildings water system, or any information that was stated in the policy. On 1/30/25 at 12:12 PM the surveyor interviewed Staff #9 from maintenance, to discuss the Legionella water management program. Surveyor reviewed with Staff #9 the information that was provided to the survey team, what the policy stated and how none of the information was provide in a written form. Surveyor asked Staff #9 to explain what the plan was for prevention of Legionella and other waterborne pathogens. Staff #9 admitted that he did not have a plan in place but understood what was needed to be completed. 51786 2) Enhanced Barrier Precautions (EBP) refers to a healthcare practice where staff are required to wear gowns and gloves during high-contact resident care activities for certain individuals. On 1/27/25 at 11:37 AM an interview and observation were conducted with Resident #85. The resident stated he/she had a wound on the right shoulder and the right hip. He/She said the right hip wound was healed but the right shoulder wound required a dressing change daily. Wound care supplies were observed on top of the bedside drawer. On 1/31/25 at 11:00 AM, an observation was made of Resident #85's right shoulder wound dressing change by a Licensed Practical Nurse (LPN #3). The LPN donned clean gloves and removed the resident's dirty dressing. After she removed the dirty dressing, LPN #3 removed her dirty gloves and put on clean gloves, cleansed the wound and applied a clean dressing to the resident's right shoulder wound. On 1/31/25 at 11:13 AM, immediately after the dressing change, an interview with LPN #3 was conducted outside the resident's room. On the resident's door, there was an EBP sign that indicated the provider should wear a gown and gloves when wound care was provided. When asked about the EBP sign and what to wear before a dressing change, LPN #3 confirmed that she did not wear a gown that was required as part of EBP measures. The dressing change steps were also reviewed with LPN #3 and she confirmed that she did not clean her hands after she removed her dirty gloves and before she put on clean gloves. She also confirmed that she was aware that this was a deficient practice. On 1/31/25 at 4:00 PM The Director of Nursing (DON) was asked to provide the wound care and dressing change policies. On 2/03/25 at 08:00 AM The wound care and dressing change policies were received. A review of these policies revealed that the LPN should wash and dry hands thoroughly after the removal of dirty gloves and before she donned clean gloves. On 2/03/25 at 11:00 AM The DON was asked to provide the facility's EBP policy. On 2/03/25 at 11:20 AM The EBP policy was received and a review revealed that gloves and gowns should be worn for high-contact resident care activities such as dressing change procedures. On 2/03/25 at 11:28 AM an interview with the DON was conducted to review that LPN #3 failed to perform hand hygiene and wear a gown when she changed Resident #85's wound dressing. The DON confirmed this was a deficient practice. 48259 3) An observation on 1/27/25 at 3:52 PM noted a signage on Resident #39's door that indicated the resident was on EBP, which required wearing gowns and gloves during high-contact resident care activities. Enhanced Barrier Precautions are infection control interventions designed to reduce transmission of infection in nursing homes. It involves gown and glove use during high-contact Resident care activities like dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for residents with infection or colonization of MDRO (multi-drug-resistant organisms), central line, urinary catheter, feeding tube, tracheostomy, or any skin opening requiring dressing. A subsequent observation on 1/27/25 at 3:55 PM showed that certified nursing assistants (CNAs #10 and #11) were providing incontinent care to Resident #39. Both CNAs had put on gloves, but the observation failed to show that they wore gowns. A record review later that day noted that Resident #39 had been treated for an MDRO urinary tract infection in December 2024. In an interview on 1/27/25 at 4:14 PM, CNAs #10 and #11 were asked what the EBP signage on Resident #39's door meant. Both staff stated it meant to wear gloves and a mask when providing direct care to Resident #39. Both staff continued to say that they used to wear gowns and gloves whenever they had direct contact with the resident. However, they did not see why to continue wearing gowns anymore. In an interview on 1/29/25 at 8:38 AM, RN #1, assistant director of nursing (ADON), stated that after the resident had been treated for active MDRO in December 2024, s/he was placed on EBP for the rest of her/his stay in the facility. The ADON continued to say that before staff had direct contact with the resident, they were to wear gowns and gloves. ADON also added that she was made aware of the surveyor's concerns and had provided education to GNAs #10 and #11.

Based on observations, records review and interviews, it was determined that the facility failed to ensure resident's urine collection bag was kept in a privacy bag to maintain dignity. This was evident for 1 (Resident #11) of 3 residents reviewed for dignity. The findings include: Resident #11 was admitted into the facility in 2024. During the initial tour of the facility on 1/27/25 at 9:59 AM, the resident's urine collection bag was observed by the foot of the bed with no privacy bag. The urine collection bag was visible from the hallway of the unit where the resident resided. The Registered Nurse (RN #2) who was currently assigned to Resident #11, was interviewed on 1/27/25 at 10 AM. During the interview, the concern was discussed that Resident #11's urine collection bag did not have a privacy bag applied and was visible from the unit's hallway. RN #2 came into the resident's room, confirmed the finding and indicated that she would look for a privacy bag. Afterwards, RN #2 stated, I did not find one in the room. A Foley catheter is a device that drains urine (pee) from your urinary bladder into a collection bag outside of your body when you can't pee on your own or for various medical reasons. Another name for a Foley catheter is an indwelling urinary catheter. A review of Resident #11's care plan on 1/29/25 at 8:51 AM, indicated that the resident was readmitted from the hospital with a Foley catheter in place. The interventions for this care plan included: a) Position catheter bag and tubing below the level of the bladder and away from entrance room door. b) foley catheter care shift and prn On 1/29/25 at 3:09 PM, the Director of Nursing (DON) was interviewed. During the interview, the concern was discussed that Resident #11's urine collection bag was observed with no privacy bag applied and was visible from outside the resident's room. The DON acknowledged the concern and stated, We will fix it. The DON reported that all residents with a urine collection bag will be placed in a privacy bag whether it's hung on the side away from the door or not.

Based on medical record review and interviews, it was determined that the facility failed to ensure that allegations of abuse were reported to the State Agency no later than 2 hours after the allegation was made. This was evident for 1 (#406) of 12 residents reviewed for abuse. The findings include: On 1/30/25 at 9:12 AM, a review of a facility-reported incident related to Resident #406 with MD#00203203 showed that the resident reported an allegation of abuse to an evening nursing supervisor, a licensed practical nurse (LPN #14) on the morning of 3/1/24. A record review of the facility's investigation into the abuse allegation later that day showed that the allegation was reported to the Nursing Home Administrator (NHA) on 3/4/24 at 11:15 AM. Further review of the facility's report of the allegation to the state agency revealed that the incident was initially reported to the state agency on 3/4/24 at 11:59 AM. The facility sent the final report on 3/8/25 at 3:14 PM. The review failed to show that the facility immediately forwarded a first report of the allegation of abuse to the state agency but not later than 2 hours after the facility staff became aware of the allegation. In an interview on 1/30/25 at 10:28 AM, the social services director stated that, per his written statement for 3/1/24, Resident #406 had mentioned the allegation of abuse to him on 3/1/24, at which time the facility was already aware of it and had initiated an investigation. In an interview on 1/30/25 at 12:53 PM, the director of nursing confirmed concerns and stated that the facility lacked documentation to prove that Resident #406's allegation of abuse was reported to the state agency office timely.

Based on record reviews and staff interviews, it was determined that the facility failed to ensure that thorough investigations were completed for allegations of abuse. This was evident for 3 (#59, #406, #47) out of 12 residents reviewed for abuse. The findings include: 1) A review on 1/28/25 at 2:54 PM of a facility-reported incident related to Resident #59 with MD#00201953 was done. The review showed that on 1/27/24 at approximately 8:15 AM, an environmental services aide (staff #17) alleged abuse to the facility's supervisor on behalf of Resident #59. Staff #17 reported that the resident was verbally abused by a licensed practical nurse (LPN #18) on 1/27/24 at approximately 8:15 AM. The continued review revealed that Resident #59 and his/her roommate were interviewed by staff. The review also showed that Resident #59 was assessed from head to toe and a statement by staff. However, the review lacked documentation that other residents who had been taken care of by LPN #18 that shift were assessed or interviewed by the facility. In an interview on 1/29/25 at 10:00 AM, the director of nursing (DON) stated that the facility did not have documentation showing that other residents were assessed or interviewed when the allegation was made for Resident #59. 2) A review of a facility-reported incident with MD#00203203 on 1/30/25 at 9:12 AM contained an allegation of abuse by Resident #406 involving a staff. Further review of the facility's investigation of the allegation showed that the facility staff assessed Resident #406's skin with no concerns. The review revealed statements from the alleged perpetrator and other staff who had taken care of Resident #406. The review also stated that the alleged perpetrator, an agency nursing staff, had been placed on a Do not return list to the facility. However, the review failed to show that the facility had completed a thorough investigation, including assessment and statements from other residents who had been cared for by the alleged perpetrator. During an interview on 2/3/25 at 11:21 AM, the DON said the facility lacked documentation to prove that other residents were assessed and interviewed when the allegation was made. The DON also added that the facility would include that in their investigations in the future. 51489 3) On 1/31/25 at 10:39 AM a record review of the facility's investigation file regarding facility-reported incident MD00157045 revealed: On 8/8/20 at 4:30 PM, Resident #47 complained to facility Licensed Practical Nurse (LPN) #24 about an alleged incident. On 8/8/20 at 7:35 PM, Registered Nurse (RN) #25 initiated a self-report to nh.selfreport@maryland.gov. The investigation file included several handwritten staff testimonies dated: 8/8/20 at 4 PM, 8/8/20 at 4:58 PM, 8/8/20 at 7:58 PM, 8/9/20 night shift, and 8/10/20 at 10:27 AM all of which did not support the resident's allegation. On 8/10/20, Staff #26, 1st-floor unit manager interviewed Resident #47 and concluded that Resident #47 was confused, making contradictory statements regarding the day the alleged abuse occurred. On 8/11/20 at 11:04 AM Staff #25 submitted a final report not substantiating the incident to nh.selfreport@maryland.gov. On 1/29/25 at 9:50 AM in an interview, the Director of Nursing (DON) acknowledged that an allegation of abuse should be immediately reported to the nurse on duty who then reports to the DON. The nurse who receives the initial allegation should document it in writing then the DON and another nurse interview the resident. The Nursing Home Administrator (NHA) reviews requirements and reports the incident. Facility staff interview other residents in the immediate area. On 1/31/25 at 11:13 AM, in an interview, the DON acknowledged that the investigation involving Resident #47's alleged abuse did not meet facility expectations that include other resident interviews or a resident assessment conducted by a Nurse Practitioner or Physician as part of the investigation.

Based on interviews and record review, it was determined that the facility failed to notify a resident and/or his/her representative in writing of the facility's bed hold policy upon transfer to an acute care facility. This was evident for one (#39) of 5 Residents reviewed for hospitalizations. The findings include: In an interview on 1/27/25 at 4:17 PM, Resident #39 reported that she was recently hospitalized for an infection. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. The information collected drives resident care planning decisions. A record review on 1/28/25 at 3:29 PM showed that Resident #39 had been residing in the facility since August 2023 and was alert, oriented, and cognitively intact per an MDS assessment dated [DATE]. Further review revealed a nurse's note dated 12/22/24 that indicated that Resident #39 was transferred to the hospital for lethargy, unresponsiveness, and increased tremors. However, the review failed to show that a copy of the facility's bed hold policy was mailed to the Resident's representative. In an interview on 1/29/25 at 2:39 PM, a nursing supervisor (LPN #14) reported that the facility gave the 911 staff a packet that included the facility's bed hold policy upon a resident's transfer to an acute care facility. However, a staff member from the admissions department later called the Resident's representative. During an interview on 1/29/25 at 2:48 PM, the admissions director, staff #19, said the facility's bed hold policy was not addressed with residents who resided in the facility long term but addressed it with residents who lived there for a short-term basis. Staff #19 was questioned about the bed hold policy for Resident #39 when she was transferred to the hospital on [DATE]. Staff #19 responded that the bed hold policy was not addressed with Resident #39 and/or his/her representative upon transfer to the hospital on [DATE]. In an interview on 2/3/25 at 12:34 PM, the director of nursing (DON) reported that per the nursing home administrator, he understood the concern of failing to notify the Resident and/or representative in writing of the facility's bed hold policy upon transfer to an acute hospital. The DON also added that the facility would work on fixing the concern going forward.

Based on records review, observations and interviews, it was determined that the facility failed to ensure that the resident's care plan was reviewed and revised to meet the resident's needs. This was evident for 1 (Resident #62) of 1 resident reviewed for tube feeding. The findings include: Tube feeding is a therapy where a feeding tube supplies nutrients to people who cannot get enough nutrition through eating. A flexible tube is inserted through the nose or belly area to provide nutrients by delivering liquid nutrition directly into the stomach or small intestine. Resident #62 was admitted to the facility in early 2024. A quick look into the resident's medical record indicated that s/he received tube feedings. On 1/28/25 at 10:39 AM, the resident reported that s/he received nutrients by tube feedings and by mouth. On 1/29/25 at 9:49 AM, Resident #62's care plan related to nutrition was reviewed. The review revealed interventions that indicated the resident feeds him/herself and was independent after setup. However, other interventions indicated that s/he needed supervision for all intakes. On 1/29/25 at 1:40 PM, a Geriatric Nursing Assistant (GNA #12) was interviewed about Resident #62. GNA #12 reported that she usually worked on the floor where the resident resided and was familiar with Resident #62. GNA #12 reported about the resident's usual dietary intake. She indicated that the resident was a tube feeder but also received a meal tray each time and was on a clear liquid diet. GNA #12 reported and confirmed that staff does not provide assistance with feeding other than setting up the meal tray and adjusting the bed. On 1/29/25 at 1:59 PM, a review of staff documentation on how the resident eats and drinks revealed majority of the staff had documented that the resident was independent. Shortly after at 2:PM, the Director of Nursing (DON) was interviewed and asked about how the GNA's knew the resident's level of assistance needed for different tasks or activities of daily living. The DON reported that the GNA's would look in the Kardex and indicated that she would print a copy of Resident #62's Kardex On 1/29/25 at 3 PM, a printed copy of Resident #62's Kardex was provided and reviewed. The review revealed that the Kardex had the residents' information with instructions specific to the resident's different care areas. Special Instructions on the front page, printed in bold letters, indicated 1 to 1 Supervision with any intake by mouth, Meds via Gastric tube, clear liquid diet. Do not leave tube feeding, tube feeding syringes or cups in room. On 1/30/25 at 12:14 PM, Resident #62 was observed sitting in the common area with other residents. Resident #62 had a cup of water on the table in front of him/her. No staff was observed supervising the resident. The DON was interviewed on 1/30/25 at 12:56 PM. During the interview, the concern was discussed that Resident #62's care plan had conflicting interventions regarding the level of assistance needed for eating. The DON reported that the resident was able to tolerate liquids and stated, we should change the instructions in his/her Kardex and care plan. She also reported that she would consult with the speech therapist to confirm that the resident was safe to have liquids on his/her own. The DON acknowledged the concern.

Based on observations, medical record review, and interviews, it was determined that the facility failed to ensure that a resident who could not carry out activities of daily living (ADL). This was evident for one Resident (#82) who was reviewed for activities of daily living (ADL) during the survey. The findings include: In an observation on 1/27/25 at 10:26 AM, Resident #82 was noted sitting in a wheelchair in his/her room and had long toenails on bilateral feet. The Resident's representative was present at the bedside and reported he had made staff aware of Resident #82's long toenails three weeks ago. A record review on 1/28/25 at 2:53 PM showed that Resident #82 had been living in the facility since August 2024 with diagnoses including Alzheimer's Dementia (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks). Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. The information collected drives resident care planning decisions. The continued review contained an MDS assessment dated [DATE] that recorded that Resident #82 required substantial/maximal to complete dependence on staff for his/her self-care needs. Further review of Resident #82's plan of care for self-care included an intervention initiated on 8/14/2024 that said, Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Resident #82's shower days were on Tuesdays and Fridays on the day shift. In an interview on 1/30/25 at 9:53 AM, a licensed practical nurse (LPN#23) said that the geriatric nurse aides (GNAs) were to trim the toenails of residents who were not diagnosed with diabetes on their shower days. However, earlier observation on Resident #82's shower day failed to show that his/her toenails were trimmed even though s/he was not diagnosed with diabetes. On 1/30/25 at 10:09 AM, LPN #23 observed Resident #82's toenails with the surveyor. The observation showed that the Resident's long toenails remained. LPN #23 stated that the GNAs should have trimmed the Resident's toenails. On 1/30/25 at 10:16 AM, LPN #23 reported to the surveyor that she trimmed Resident #82's toenails after the surveyor's intervention. During an interview with the director of nursing (DON) on 1/30/25 at 12:58 PM, she stated that the GNAs should have clipped Resident #82's toenails. The DON also reported that the facility would have a process to correct the concern going forward.

Based on observations, records review and interviews, it was determined that the facility failed to provide appropriate treatment and services for care of a resident with an indwelling catheter. This was evident for 1 (Resident #11) of 1 resident reviewed for urinary catheters. The findings include: Resident #11 was admitted into the facility in 2024. During the initial tour of the facility on 1/27/25 at 9:59 AM, the resident was observed in bed with the urine collection bag placed directly on the floor. The Registered Nurse (RN #2) who was currently assigned to Resident #11, was interviewed on 1/27/25 at 10 AM. During the interview, the concern was discussed that Resident #11's urine collection bag was laying directly on the floor. RN #2 came into the resident's room, confirmed the finding and hung the urine collection bag on the resident's bedframe. A Foley catheter is a device that drains urine (pee) from your urinary bladder into a collection bag outside of your body when you can't pee on your own or for various medical reasons. Another name for a Foley catheter is an indwelling urinary catheter. A review of Resident #11's care plan on 1/29/25 at 8:51 AM, indicated that the resident was readmitted from the hospital with a Foley catheter in place. The interventions for this care plan included: a) Position catheter bag and tubing below the level of the bladder and away from entrance room door. b) foley catheter care shift and prn On 1/29/25 at 3:09 PM, the Director of Nursing (DON) was interviewed. During the interview, the concern was discussed that Resident #11's urine collection bag was observed laying directly on the floor. The DON verbalized understanding and acknowledged the concern.

Based on observation and interviews, it was determined that the facility failed to ensure that a resident was served a meal according to a predetermined menu that incorporated the resident's preferences. This was evident from one observation made during the survey. The findings include: On 1/30/25 at 12:30 PM, the surveyor requested a test tray while observing the lunch tray line. The observation showed a meal ticket on the tray for Resident #51 that listed smothered pork chop for entree, 1/2 cup mashed potatoes for starch, 1/2 cup seasoned zucchini for vegetable, 1 white dinner roll, 1pkg [package] pepper and 1 butter for condiment, 1/2 cup cinnamon applesauce, 4oz iced tea for beverage and 4fl.oz water. However, further observation showed that the tray contained an apple pie, pork chop, mashed potatoes, seasoned zucchini, white dinner roll, pkg pepper, and one butter. The Food service manager was present and was made aware that Resident #51's meal ticket listed 1/2 cup of cinnamon applesauce as dessert; however, the observation found apple pie on the tray. And he said, the dietary staff should have put apple sauce on the tray and not apple pie as Resident #51's food texture was mechanical soft and not regular. The nursing home administrator was notified of the above concerns on 2/3/25 at approximately 3:00 PM, and he stated that he was already made aware of the concern.

Based on review of facility documents and staff interview, it was determined that the facility failed to report an allegation of abuse to the State Survey Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours after the abuse allegation was made. This was evident for 1 (#1) of 1 residents reviewed for abuse. The findings include: On 6/15/21 at 1:30 PM, a review of the facility reported incident MD 350 was conducted related to an allegation of abuse involving Resident #1. The facility documentation indicated that, on 4/21/21 at 4:00 PM, the facility staff received a phone call from a family member reporting the alleged abuse of Resident #1. The email confirmation of the facility's report to the state agency revealed documentation that the allegation of abuse was reported to the state agency on 4/22/21 at 11:17 AM, which was 1 day after the allegation of abuse was reported to the facility. The facility failed to report the allegation of abuse immediately but not later than 2 hours following the event that caused the allegation. On 6/15/21 at approximately 1:30 PM, the concerns related to timely reporting an allegation of abuse were discussed with the Director of Nurses.

Based on interview and review of facility reported incident (FRI) investigation documentation, it was determined that the facility failed to thoroughly investigate an allegation of abuse. This was evident for 1 (#1) of 1 residents reviewed for abuse. The findings include: On 6/15/21, at approximately 1:00 PM, the surveyor requested a copy of all the facility's documentation of their investigation of the facility reported incident MD 358 related to an allegation of abuse involving Resident #1. On 6/15/21 at 1:30 PM, the facility provided the surveyor of with a copy of a 1 page Comprehensive & Extended Care Facilities Self-Report form that was provided to the State Agency, which is the Office of Health Care Quality, and the email receipt confirmations from the state agency. A review of the facility's self-report form was conducted. The report form documented that a resident's family member reported the alleged incident of abuse to the Social Worker on 4/21/21 at 4:00 PM. There was no other documentation by the Social Worker of his/her conversation with the complainant. The report form indicated that the resident was called and interviewed on 4/21/21 with no documentation of the time of the interview. The report indicated there was a person involved in the incident that the resident identified by name. The facility determined the person the resident identified was not employed as clinical staff, however at the time of the investigation, the facility had not determined the person was not employed at the facility. The report documented a conversation was had with the resident's family member, however there was no date or time to indicate when the conversation occurred. Continued review of the facility's investigation documentation failed to reveal that any potential witnesses had been interviewed or statements obtained. There was no evidence that the clinical staff who were assigned to care for the resident during the time of the alleged incident had been interviewed. There was no documentation of interviews or statements from other staff or residents. The facility failed to provide evidence that a thorough investigation was conducted to determine whether the alleged abuse had occurred. On 6/16//21 at approximately 4:15 PM, during a conversation, the facility's Chief Executive Officer was made aware of the concerns related to failing to thoroughly investigate the resident's allegations and confirmed the findings at that time.

Based on resident interview, staff interview, clinical record review, and a review of the facility abuse investigation it was determined that the facility staff failed to ensure that residents were free from abuse. This was evident for 6 (#8. #29, #63, #2[AGE], #289, #290) of 6 residents involved in Facility Reported Incident #MD [AGE]5. The findings include: Review of Facility Reported Incident MD [AGE]5 revealed an allegation that a Certified Nursing Assistant (CNA, Staff #7) had been verbally abusive towards residents. On 3/8/19, Geriatric Nursing Assistants (GNA) #5 and #6 approached the Director of Nursing (DON) with concerns they had regarding CNA #7's interactions with residents on 3/7/19 and 3/8/19. An email from GNA #5 stated that, on 3/8/19, CNA #7 had asked GNA #5 to assist with Resident #29's care. While performing Resident #29's care, GNA #5 heard CNA #7 call the resident a beast and stated that Resident #29 was a miserable person. Review of a written statement from GNA #8 confirmed that CNA #7 called Resident #29 a beast and yelled at the resident. An email from GNA #6 stated that, on 3/8/19, CNA #7 went into Resident #289's room in response to a call light and stated to the resident unless you are dying do not hit this light anymore. GNA #6 later asked CNA #7 for help transferring Resident #63 during which time CNA #7 made remarks in front of the resident including I f****ing hate this place, this s*** is for the birds, I'm over all these needy a** people, if you wouldn't take 2 hours to wash up we wouldn't have to deal with this and come on you're breaking my back while transferring the resident. GNA #6 went on to state that CNA #7 also called Resident #8 a fat a** while pulling them up in bed. Around 10:00 AM, the same day, Resident #2[AGE] was having trouble swallowing medication and CNA #7 laughed at the resident, picked up a pillow from the chair and stated let me just give them some pillow therapy and held the pillow up as if putting it over the residents face. This was confirmed in a written statement by Licensed Practical Nurse (LPN, Staff #10) and Staff #11. A written statement from GNA #8 revealed that CNA #7 had called Resident #290 a rude old person. CNA #7 also expressed their desire for Resident #290 to report the CNA so they could be sent home. When Resident #290 asked CNA #7 why they worked there if they hate it so much, CAN #4 responded that they hate working with such miserable people. A written statement from GNA #9 stated that, on 3/8/19 at 10:20 AM, Resident #290 had exclaimed I hope you didn't bring CNA #7 when providing care. Resident #290 went on to state that CNA #7 had instructed the resident Go tell them I'm being mean so I can go home. Resident #290 expressed that she wished CNA #7 would stop saying they were mean because they are not mean. When told that CNA #7 would not be taking care Resident #290 that day, the resident said Thank God. CNA #7 was interviewed on 3/8/19 by the DON, Director of HR and the Unit Manager during which time CNA #7 admitted to saying Resident #2[AGE] needed pillow therapy but denied all other allegations. CNA #7 was subsequently suspended pending investigation of the allegations. The facility substantiated verbal abuse to multiple residents and on 3/11/19, CNA #7 was terminated for their actions and reported to the Maryland Board of Nursing. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 2/5/20.

Based on record review and interview with staff, it was determined that the facility staff failed to develop a comprehensive resident centered care plan, including measurable objectives and timeframes to meet the resident's identified needs in order to attain or maintain the highest practicable level of well-being. This was evident for 4 (#53, #[AGE], #64 and #74) of 47 residents reviewed during the recertification survey. 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's care. The findings include: 1) On 1/28/20 at 10:14 AM, during an interview with Resident #53, the surveyor observed a large raised egg shaped area on the resident's right shin. The area was approximately 2 inches wide by 4 inches long, 1 inch high and was pink. The resident indicated it was the result of a fall. Review of the resident's record, on 1/29/20 at 11:09 AM, revealed a nursing progress note, dated [DATE] at 10:24 (AM), indicating the resident was found lying on the floor in his/her room and had a hematoma to RLL (right lower leg). Ice was applied. Additional progress notes on 1/16/20, 1/22/20, [DATE] and 1/28/20 document the area and it's condition. Resident #53 had a plan of care for Tissue Integrity which included Has hematoma to the RLE. The resident's goal was: Complications to his/her tissue integrity related to confounding factors will be minimized with routine monitoring and preventative measures in place daily times 90 days. The approaches were preventative and included weekly skin assessments. The plan did not include interventions related to the hematoma. A care plan evaluation note reflected that the resident was started on antibiotic therapy on 1/20/20 after an evaluation by the Nurse Practitioner, however, the care plan did not address interventions related to the care and monitoring of the hematoma. During an interview on 1/29/20 at 12:49 PM, Staff #14 an LPN (licensed practical nurse) was asked about the care Resident #53 was receiving related to his/her hematoma. She indicated that it was put on the board in the nurse's station for 3 days. The board lists residents with changes. When asked what was currently being done, she indicated that staff were keeping an eye on it, and reporting on it each day. When asked how it is monitored, she indicated that it is usually measured on skin sheets, but that they were not currently measuring it. She indicated that she thought it would have resolved by now. The facility staff failed to develop and implement a plan of care reflecting services to be furnished to attain the resident's highest practicable level of well-being including measurable objectives and timeframes related to Resident #53's hematoma. On 1/29/20 at 2:10 PM, the DON (Director of Nursing) was made aware and confirmed the above concerns. 2) Resident #[AGE]'s medical record was reviewed on 2/4/20 at 11:52AM. The resident's [DIAGNOSES REDACTED]. Physicians orders to manage the residents Diabetes included Tresiba FlexTouch ([MED]) 15 units daily with breakfast for DM (Diabetes Mellitus); FSBS (finger stick blood sugar) check every day in evening for DM; Carbohydrate Controlled diet, No added salt, mechanical soft texture, thin liquids and Diabetic Snack by mouth at bedtime for DM. Additional physicians' orders were written for several interventions to be implemented as needed for [DIAGNOSES REDACTED] (low blood sugar) Protocol. Resident #[AGE] had several physicians orders for care related to his/her renal and [MEDICAL TREATMENT] needs including [MEDICAL TREATMENT] on M-W-F (Monday, Wednesday and Friday) at MMC (Meritus Medical Center); Rena-Vite and [MED] supplements daily for [MEDICAL TREATMENT]; Document dry weight when returns from [MEDICAL TREATMENT]; Check [MEDICAL TREATMENT] communication sheet for orders, updates or recommendations when resident returns from [MEDICAL TREATMENT]; Check right arm fistula skin integrity and for bruit/thrill every shift; [MEDICAL TREATMENT] fistula to right arm; No BP (blood pressure or IV's to right arm; Reinforce dressing to [MEDICAL TREATMENT] catheter site as needed; Check vital signs after [MEDICAL TREATMENT] and document; [MEDICATION NAME]-[MEDICATION NAME] topical cream 1 hour prior to [MEDICAL TREATMENT]. During further review of the record, the surveyor was unable to find that care plans had been developed to guide the care and services Resident #[AGE] was to receive related to his/her diabetes and renal/[MEDICAL TREATMENT] needs. During an interview on 2/5/20 at 10:35 AM, the director of nursing (DON) confirmed that the facility staff failed to develop care plans to plan, assess and evaluate the effectiveness of Resident #[AGE]'s diabetes and renal/[MEDICAL TREATMENT] care needs. 3) Resident #64's medical record was reviewed on 1/29/20 at 11:19 AM. Resident #64's admission assessment, with a reference date of [DATE], Section C. Cognitive Patterns, documented that Resident #64's BI[CONDITION] (brief interview for mental status) score was 5, indicating the resident had severe cognitive impairment, Section E, Behavior, did not identify any behaviors for Resident #64 and Section, I, Active Diagnosis, indicated the resident had [DIAGNOSES REDACTED]. On [DATE] at 1:44 PM, in a progress nurse, the CRNP (certified registered nurse practitioner) documented that Resident #64's [DIAGNOSES REDACTED]. Review of Resident #64's January 2020 MAR (medication administration record) revealed documentation that Resident #64 received [MEDICATION NAME] (Quetiapine) (antipsychotic) by mouth for dementia with behavioral disturbance, every other day in January until 1/26/20. Review of Resident #64's care plans revealed a care plan, Resident #64 receives antipsychotic medication for management of dementia with behaviors that had the goal, Resident #64 will receive lowest therapeutic dose for control of symptoms by/through review date. The care plan, was not comprehensive with measureable goals that were developed to address the resident's dementia care needs as identified in the comprehensive assessment. 4) On 1/31/20 at 11:02 AM, Resident #74's medical record was reviewed and revealed the resident had [DIAGNOSES REDACTED]. Resident #74's January 2020 MAR indicated [REDACTED]. Review of Resident #74's care plans revealed a care plan, Resident #74 receives antidepressant medication for management of depression [DIAGNOSES REDACTED].#74 will receive lowest therapeutic dose for control of symptoms by/through the review date. The care plan was not resident centered and failed to identify the symptoms for which the antidepressant was prescribed. Continued review of Resident #74's care plans failed to reveal that a comprehensive, resident centered care plan had been developed to address Resident #74's mood and depression for which an antidepressant had been prescribed. The Director of Nurses was made aware of these findings on 2/4/20 at 11:07 AM.

Based on medical record review and interviews with facility staff, it was determined the facility's clinical pharmacist failed to clearly indicate if irregularities were found or not found during the monthly drug regimen reviews. This was evident for 2 (#138 and #45) of 6 residents reviewed for unnecessary medication. The findings include: During a review of Resident #138's medical record on 1/31/20 at 1:36 PM, the surveyor reviewed the clinical pharmacist's monthly drug regimen reviews for the time period 2/21/19 - [DATE]. The pharmacy review note, dated 2/21/19, included comments, but did not indicate if irregularities were found during the review. However, an irregularity was found, a pharmacist recommendation referral was made to the physician on 2/21/19 and was addressed by the practitioner. Pharmacist reviews conducted and noted on 6/26/19, [DATE], 9/25/19 and [DATE] failed to document either that no irregularity was identified or the nature of any identified irregularities. The Director of Nursing was made aware of these findings on 2/4/20 at 8:33 AM. On 1/30/20 at 9:30 AM, medical record review for Resident #45 revealed Monthly Medication Reviews (MMR) for October, November and December 2019 that did not specify if irregularities were found by the pharmacist. The Director of Nursing (DON) was interviewed on 1/30/20 at 9:53 AM and stated that pharmacists leave a note in the resident's electronic record that the MMR was completed, however, pharmacists do not mention in this note if there were irregularities or no irregularities. Review of the facility's pharmacy reports for October, November and December 2019 confirmed that it was not noted if Resident #45 had irregularities or had no irregularities in their medication regimen - only that the resident was seen by the pharmacist. Pharmacy notes from 10/25/19, [DATE] and 12/24/19 failed to document if any irregularities were found. Interview with the DON on 1/30/20 at 10:33 AM confirmed that the facility only receives a report on residents with recommendations from the pharmacist.

Based on resident interview and surveyor observation, it was determined the facility failed to provide food at an appetizing temperature. This was evident for 1 (#19) of 47 residents in the sample. The findings include: On [DATE] at 11:23 AM, Resident #19 stated that the food was often cold. On 11/28/20, during interviews with Residents #12, #65 and #74, it was revealed that food was sometimes cold when brought to the residents. On 1/30/20 at 12:13 PM, Resident #19 was observed with two lunch trays in their room. Interview with Resident #19 revealed that the first tray did not match their lunch request so an additional meal tray was brought which was observed laying covered on the resident's bed. With Resident #19's permission, the food was uncovered and the temperature was measured. The ham measured 104 F and the green beans measured 110 F. Resident #19 confirmed that this was not an appetizing temperature and stated that staff would reheat food if requested. The Administrator and Director of Nursing were made aware of the findings during the exit conference on 2/5/20.

Based on medical record review and staff interview, it was determined that the facility failed to keep complete and accurate medical records. This was evident for 3 (#196, #36 and #14) of 3 residents reviewed for advanced directives and 1 (#[AGE]) resident reviewed for death, of 3 residents reviewed during closed record review. The findings include: 1) On [DATE] at 2:10 PM, a review of Resident #196's medical record revealed 2 physician signed MOLST form (Maryland Medical Order for Life Sustaining Treatment) (documents a person's wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatments). One MOLST form, signed and dated [DATE], documented that Resident #196 elected No CPR, Option A, Comprehensive Efforts to Prevent Arrest: Prior to arrest, administer all medications needed to stabilize the patient . If cardiac and/or [MEDICAL CONDITION] arrest occurs, do not attempt resuscitation (No CPR). Allow death to occur naturally and selected Option A-2, Do not intubate (DNI): Comprehensive efforts may include limited ventilatory support by [MEDICAL CONDITION] or [MEDICAL CONDITION], but do not intubate. The second MOLST form, signed and dated [DATE], documented the resident's health care agent elected No CPR, Option B, Palliative and Supportive Care: Prior to arrest, provide passive oxygen for comfort and control of any external bleeding. Pror to arrest, provide medications for pain relief as needed, but no other medications. Do not intubate or use [MEDICAL CONDITION] or [MEDICAL CONDITION]. If cardiac and/or [MEDICAL CONDITION] arrest occurs, do not attempt resuciatiaion (No CPR), Allow death to occur naturally. Page 2 of the MOLST documented Resident #196's preferences that applied to other situations other than cardiopulmonary arrest. The practitioner failed to void Resident #196's MOLST form dated [DATE] when a new MOLST form was created on [DATE]. 2) Resident #36's medical record was reviewed on [DATE] at 2:13 PM. Review of Resident #36's electronic medical record revealed 2 physician signed MOLST forms. One MOLST, signed and dated [DATE], documented that Resident #36 elected Attempt CPR indicating if cardiac and/or [MEDICAL CONDITION] arrest occurs, attempt CPR. The second MOLST, signed and dated [DATE], documented Resident #36 elected No CPR, Option B, Palliative and Supportive Care. Page 2 of the MOLST documented Resident #36's preferences that applied to other situations other than cardiopulmonary arrest. The practitioner failed to void Resident #36's MOLST form dated [DATE] when a new MOLST was created on [DATE]. Resident#36's [DATE] MAR (medication administration record) revealed an order for [REDACTED]. On [DATE] at 12:58 PM, the ADON (Assistant Director of Nurses) was made aware of the findings. On [DATE] at 1:44 PM, the ADON explained to the surveyor that there had been a glitch in the computer when the order was added to the EMR (electronic medical record). At that time, the surveyor was provided with a copy of the hand written telephone order that indicated the dose of the [MEDICATION NAME] was 40 mg (milligram) and a copy of the medication pack provided by the pharmacy that indicated the [MEDICATION NAME] dose was 40 mg. Continued review of Resident#36's [DATE] MAR indicated [REDACTED] 1) [MEDICATION NAME] 15 40% oral gel ([MEDICATION NAME]) (natural sugar produced by the liver), dose is 15 grams; give per [DIAGNOSES REDACTED] Protocol - 1 application [MEDICATION NAME] (in the cheek) as needed for [DIAGNOSES REDACTED] protocol, 2) [MEDICATION NAME] Diagnostic Kit 1 mg/ml Injection (shot) ([MEDICATION NAME]) (treats [DIAGNOSES REDACTED]), dose is 1 mg (milligrams) Give per [DIAGNOSES REDACTED] protocol. There was no clear indication how to inject the medication. The order did not indicate whether the medication was to be injected intramuscularly (in the muscle) or subcutaneously (in the fat between the skin and the muscle). 3) [MEDICATION NAME] 50% in water (D50W) intravenous (IV) syringe 0.5 g (grams)/ml (milliliter), dose is 25 grams. Give per [DIAGNOSES REDACTED] protocol. The order did not indicate the route to be used to administer this medication. The order did not clearly indicate how this medication was to be administered except for indicating it should be in an IV syringe. On [DATE] at 4:44 PM, the Director of Nurses was made aware of the above findings and stated that the facility's hypoglycemic protocol had been around a long time and indicated she was unsure if the facility nurses were aware of the [DIAGNOSES REDACTED] protocol. A copy of the facility's hypoglycemic protocol was provided to the surveyor and reviewed by the surveyor. 3) Resident #14's electronic medical record (EMR) was reviewed on [DATE] at 3:04 PM. A MOLST form, dated [DATE], indicated by the practitioner's initials in section 1 that the resident's informed consent choice was: No CPR, Option A, Comprehensive Efforts to Prevent Arrest: Option A-2, Do Not Intubate (DNI). Directly below this, another option No CPR, Option B, Palliative and Supportive Care was also initialed by the practitioner with a diagonal line drawn through the initials. The form was not accurately and legibly completed with only 1 choice. The instructions for this form indicated that the physician or nurse practitioner must accurately and legibly complete the form and select only 1 choice in section 1. It was not clear as to when each of the choices in section 1 were completed nor when the diagonal line was drawn through Option B. Resident #14's paper record was reviewed on [DATE] at 1:10 PM. One MOLST form was found in this record and was dated [DATE]. Section 1 indicated that the resident's informed consent choice was No CPR, Option A, Comprehensive Efforts to Prevent Arrest: Option A-2, Do Not Intubate (DNI). The resident's EMR was reviewed at that time and still contained the MOLST form dated [DATE]. The facility failed to maintain clear and accurately documented records by failing to ensure that Resident #14's invalid MOLST form was voided when a new form was created. The director of nursing was made aware of these findings. 4) Resident #[AGE]'s medical record was reviewed on [DATE] at 11:52 AM. The record revealed that the resident's [DIAGNOSES REDACTED]. Physician orders were written for Tresiba FlexTouch ([MED]) 15 units daily with breakfast for DM, FSBS (finger stick blood sugar) check every day in evening for DM, Carbohydrate Controlled diet, No added salt, mechanical soft texture, thin liquids and Diabetic Snack by mouth at bedtime for DM. Additional physician's orders were written for [MEDICATION NAME] Diagnostic Kit 1mg/ml (milligrams per milliliter) Injection ([MEDICATION NAME] (human recombinant)) (Dose is 1mg (milligram) Give per [DIAGNOSES REDACTED] Protol.) 1mL Other As needed for [DIAGNOSES REDACTED] Protocol, [MEDICATION NAME] 50% in water (D50W) intravenous syringe 0.5g/mL (grams per milliliter) (Dose is 25 grams. Give per [DIAGNOSES REDACTED] Protocol.) 50 mls Intravenous As needed for [DIAGNOSES REDACTED] protocol and [MEDICATION NAME] 15 40 % oral gel([MEDICATION NAME]) (Dose is 15 grams. Give per [DIAGNOSES REDACTED] Protocol.) - 1 applic. [MEDICATION NAME] As needed for [DIAGNOSES REDACTED] Protocol. The physician's orders did not include parameters for staff to determine when to administer each medication. [DIAGNOSES REDACTED] protocol was not included in the physician's orders nor in Resident #[AGE]'s Medication Administration Record [REDACTED] Further review of the record revealed a nursing progress note, dated [DATE] at 13:22 (1:22 PM) indicating a late entry for 12:30 PM that resident #[AGE] had vomited twice. Additional progress notes over the next 24 hours indicated that the resident was having additional episodes of nausea and vomiting, that medications were provided and effective for vomiting and that the resident was provided with snacks and meals as tolerated. A progress note entry by Staff #15 dated [DATE], as a late entry for [DATE] at 4:56 PM, indicated that the resident had no vomiting so far in the shift. His/her finger stick blood sugar (FSBS) was 61 (blood sugar readings below 70 are considered hypoglycemic). The resident was given cereal and whole milk and his/her follow up FSBS was 74. Subsequently, the resident was awaiting dinner, was lethargic but was responsive to verbal and tactile stimuli. Another late entry progress note by Staff #15 dated [DATE] for [DATE] at 9:00 PM, indicated that Resident #[AGE]'s [MED] dose was held due to nausea and vomiting and his/her FSBS running ,[DATE] as checked by Staff #15 throughout the evening. A review of Residents recorded blood sugar results in the EMR reflected entries of 119 on [DATE] at 4 PM, 68 on [DATE] at 3:56 PM and 61 on [DATE] at 4:00 PM. No documentation was found of the blood sugar results ranging from 61 - 89 on [DATE] as indicated in the nursing progress note. During an interview on [DATE] at 1:35 PM, the director of nursing (DON) was asked if the nurse completed an SBAR (a type of change in condition progress note) or otherwise document the resident's low blood sugar, she indicated no. The DON was made aware of these concerns at that time.

Based on review of previous annual surveys and deficient practices identified during this survey, it was determined that the facility failed to have an effective Quality Assurance Program as evidenced by the identification of 4 repeat deficiencies. The failure to identify and develop appropriate plans of corrections to correct quality deficiencies places all residents at risk. The findings include: The repeat deficiencies reviewed included 1) maintenance and housekeeping services related to repeat issues with vinyl armrests on wheelchairs being in disrepair, 2) notice of transfers did not include the reason for the transfer, 3) failure to ensure residents were notified of the facility's bed hold policy upon transfer, and, 4) development and implementation of comprehensive care plans. On 2/4/20 at 1:42 PM, during an interview, the concerns regarding repeat deficiencies and the failure of the previous plan of correction to address issues with the QA process were discussed with the Director of Nursing and the Quality Assurance Coordinator, who acknowledged surveyor concerns. Cross Reference F 5[AGE], F 623, F 625, F 656