Every finding on record at Future Care Chesapeake

Based on administrative reviews and interviews it was determined the facility failed to ensure that nursing staff members complete skills-based competency training annually. This was evident for 1 of 4 GNAs personnel files reviewed (GNA #15) and 1 out of 1 RN (RN #13) during the investigation phase of a recertification survey. The findings include:On 02/04/2026 at 10:00 AM the surveyor initiated the employee record review of nursing personnel which revealed: GNA #15 was hired on 01/28/2014. Additionally, the employee's personnel file did provide evidence of annual clinical skills competency training documentation between 2015 and 2024.RN #13 did not have annual clinical skills training documentation present in the employee file for years 2023 and 2024. RN #13 was hired on 06/22/2022.On 02/04/2025 at 10:25 AM the surveyor was provided with a copy of performance evaluation policy by the facility. The policy stated: Each employee will have an annual performance evaluation that reviews performance based on expectation identified in the job description. The immediate supervisor is responsible for completion of the evaluation, which becomes a part of the individuals permanent record. The facility did not provide the surveyor with a copy of the policy related to annual clinical training for licensed RN, LPN, or GNA staff prior to the exit conference.On 02/04/2025 at 12:00 noon the surveyor interviewed the DON and the HR manager who confirmed the results of the findings of the personnel files of the employees. Also, the DON and HR manager stated that the facility was unable to provide proof of skills competency evaluations for the staff listed above. The results of the surveyor's review of the facility personnel files were discussed during the exit conference on 02/04/2026.

Based on review of Geriatric Nursing Assistants' (GNAs)personnel files and staff interviews it was determined that the facility failed to ensure that annual performance evaluations were completed at least every twelve months. This was evident for 2 (GNA #15, GNA #9) out of 4 GNA personnel files reviewed during a recertification survey.The findings include: The annual performance evaluation identifies what clinical competency skills the geriatric employee should improve or maintain based on the annual 12-hour competency skills training required for geriatric nursing assistants.A review of the personnel files of four GNA employees was conducted between 10:00 AM and 12 noon on 02/04/2026. GNA #15's personnel record revealed there were no annual performance evaluations found between the years of 2016 through 2026. GNA #15 was hired on 01/28/2014 per the facility personnel file. GNA #9 did not have an annual performance evaluation present for years 2024 or 2025 and was hired on 07/26/2023. At 12 noon on 02/04/2026 the surveyor reviewed the personnel file findings with the Director of Nursing and the Human Resources Manager. The human resources manager confirmed the facility could not provide evidence of the annual performance evaluations being performed during the time periods listed above.This deficient practice was reviewed during the exit conference on 02/04/2026.

Based on observation, interview, and record review, it was determined that the facility failed to maintain the food service area in a sanitary manner and failed to properly store and label food items. This deficient practice was evident for the kitchen area observed during the recertification survey.The findings include: 1. On 01/29/26 at 7:28 AM, during observation of the main kitchen, the following sanitary concerns were identified:A box containing cans of ginger ale and tomato juice was stored directly on the floor in close proximity to the hand sink floor drain.A spice rack contained an open container of dill weed, approximately two-thirds full, which was undated.Debris was observed in the floor drain located beneath the dishwasher.A pair of used plastic foodservice gloves was observed on the floor near the dishwasher.Multiple broken floor tiles were noted near the dishwasher, with standing gray water present within the crevices.Brown, dried stains were observed on the wall adjacent to the handwashing sink. 2. At 7:31 AM, observation of a freestanding refrigerator unit located in the kitchen revealed:Two hard-boiled eggs and two muffins wrapped together in plastic wrap with no labels or dates.Two containers of applesauce marked with a preparation date of 01/24 and a use-by date of 01/27, which were expired at the time of observation. 3. Observation of the dry storage area revealed:A broken floor tile partially covering the area from which it was missing.A box of condiments stored on a shelf without any date indicating when the items were received into the facility, while other items in the area were appropriately marked with received dates.On 02/02/26 at 12:48 PM, an interview was conducted with Staff #14 regarding the observed concerns related to missing dates on food items, expired and unlabeled food, debris in floor drains, used gloves on the floor, and the broken tiles, some of which were collecting standing water. At that time, the brown stains on the wall adjacent to the hand sink had been cleaned and the used gloves were no longer present on the floor. A walkthrough of the kitchen revealed debris was still present in the floor drain. Staff #14 stated these concerns would be addressed right away.During the same interview, Staff #14 acknowledged the broken floor tiles and standing water as a concern and stated there were plans to renovate the kitchen and replace the flooring.

Based on medical record review and interviews, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices that accurately documented the resident current medical diagnosis. This was evident for 1 (resident #3) out of 9 residents reviewed during the recertification survey.The findings include: Review of resident #3 medical record on 02/03/2026 at 09:19 AM revealed a Care Plan Problem dated 12/15/2025 stating that the resident has potential safety risk r/t seizure disorder as evidenced by medication management, a current medication order dated 12/02/2025 for Lamotrigine Oral Tablet 200mg give 1 tablet by mouth one time a day for Seizure and a psychiatric note dated 01/29/2026 stating resident is taking medication Lamotrigine for a diagnosis of Bipolar Disorder. Further review revealed a Diagnosis Report listing all resident #3 diagnoses which did not list a diagnosis of having a seizure disorder. During an interview on 02/03/2026 at approximately 10:00 AM staff member #8 stated and agreed, There is no diagnosis listed or medical documentation in resident #3 medical records confirming that resident #3 has a seizure disorder. On 02/03/2026 at 12:45 PM, after surveyor intervention, staff member #8 provided documentation revealing an updated medication order for resident #3 dated 02/03/2026 stating Lamotrigine Oral Tablet 200mg give 1 tablet by mouth one time a day for Bipolar Disorder.

Based on observations, interviews and record reviews it was determined that the facility failed to ensure that medications were secured and stored safely. This was found to be evident for 5 out of 7 observations for medication storage during the recertification survey. The findings include: Insulin is a hormone that helps regulate blood sugar levels by moving glucose from the bloodstream into cells for energy. Insulin therapy often is an important part of diabetes treatment. It helps keep blood sugar under control and prevents diabetes complications. It works like the hormone insulin that the body usually makes. 1) During a medication observation conducted on 09/05/24 at 8:00 AM, this Surveyor inspected Registered Nurse (RN) #4's medication cart. The Surveyor discovered an unopened Lispro Kwikpen 100/u/ml insulin pen for Resident #63. The insulin pen was dated 08/30/24 and stored in a plastic bag that had a pharmacy label on it that said refrigerate until open. Following the observation, an interview was conducted with RN #4 who confirmed the insulin pen had not been opened. The RN stated that the facility's expectation is that the pharmacy instructions were to be followed, and the insulin pen should have been refrigerated until opened. The RN further stated that the insulin pen would be discarded and reordered. During a review of Resident's Medication Administration Record (MAR) conducted on 09/05/24 at 9:17 AM it was revealed that Resident #63 had an order for HumaLOG KwikPen Solution Pen-injector 100 Unit/ML (millimeter) (Insulin Lispro) inject as per sliding scale. 2) During a medication observation conducted on 09/06/24 at 8:22 AM, this Surveyor inspected Licensed Practical Nurse (LPN) #22's medication cart. The Surveyor discovered an unopened Lispro Kwikpen 100/u/ml insulin pen for Resident #60. The insulin pen was dated 08/30/24 and stored in a plastic bag that had a pharmacy label on it that said refrigerate until open. 3) A continued inspection of LPN #22's medication cart revealed multiple loose pills in the bottom of the second drawer: 3 loose pink tablets, 2 loose white tablets, 1/2 pink tablet, 1 orange and blue capsule. Following the observations, an interview was conducted with LPN #22 who confirmed that the insulin pen that was stored in a plastic bag had not been opened. She confirmed that the plastic bag had a pharmacy label that stated refrigerate until open. The LPN further stated that she would speak with her Unit Manager to receive directions on disposing of the insulin pen and loose tablets and reordering the insulin pen. During a review of Resident's Medication Administration Record (MAR) conducted on 09/06/24 at 9:49 AM it was revealed that Resident #60 had an order for Insulin Lispro Solution (Insulin Lispro) Inject as per sliding scale. 49815 4) During the initial tour of Nursing Unit 3 at 11:45 AM on 9/3/2024 the surveyor observed Resident #46 lying down in bed. On the overbed table in Resident #46's room was a medication cup with one pink tablet in the medication cup at the resident's bedside. The surveyor interviewed the Assistant Director of Nursing/IP (ADON/IP) on 9/3/24 at 11:49 AM who was walking by Resident #46's room at the time of the surveyor observation of the medication at Resident #46's bedside. The surveyor asked the ADON/IP what the expectation was for medications at the resident's bedside and the ADON/IP stated that medication should not be left at the resident's bedside. The ADON/IP removed the medication cup with the one pink tablet from Resident #46's overbed table and indicated that he would investigate the medication. The ADON/IP returned to the surveyor and stated that the pink tablet was PreserVision and that this was confirmed with Resident #46's nurse. On 9/12/2024 at 9:30 AM the surveyor reviewed Resident #46's medical record specifically the physician orders for the month of September 2024. According to the physician orders for Resident #46, there is a medication order for PreserVision AREDS 2 Oral Tablet Chewable (Multiple Vitamin w/Minerals). Give 1 tablet by mouth one time a day for macular degeneration. 14894 5) This surveyor was touring the facility on 9/3/24 when an unlocked medication cart was observed at 11:10 AM. The medication cart was located next to room [ROOM NUMBER]. One staff member was observed walking past the cart at 11:13 AM and then a second staff member wearing a white lab coat with a stethoscope around her neck walked past the cart. A resident wheeled past it in their wheelchair at 11:17 AM followed by a staff member wearing black scrubs. A nurse, staff #26, walked past the cart at 11:19 AM while pushing a medication cart of her own and used her left hip to lock the cart. She was interviewed and confirmed it was unlocked. The Director of Nursing was interviewed on 9/4/24 at 11:53 AM. He was informed of the findings, and he said he would investigate.

Based on record review and staff interview it was determined that the facility failed to ensure that all allegations of abuse were reported to the state agency (SA) within the required reporting timeframe. This was evident for 3 (#100, #69, and #2 ) of 5 residents reviewed for abuse. The findings include: 1) Review on 9/18/24 at 12:06 PM of the facility's investigation filed for the facility reported incident #MD00198616 revealed Resident #100 reported an allegation of abuse to facility staff. According to the statement written by the Social Worker the report of abuse was made on 10/6/23 at 12:15 PM. On 9/19/24 at 9:41 AM a review of the facility email confirmation, sent by the Director of Nursing (DON), revealed that the report had not been sent to the SA until 10/6/23 at 3:14 PM, which was beyond the 2-hour timeframe. An interview with the DON on 9/19/24 at 12:14 PM revealed that the facility had not developed a process to ensure timely submission of allegations of abuse related to the information requested on the facility report form and the approval from the corporate level before sending the report. The NHA was made aware of the concerns at 12:30 PM and confirmed what the DON had reported. 48393 2) A review of a facility reported incident, MD00199051, revealed Resident #69 had an x-ray ordered and completed in the facility on 10/25/23 at 2:09 PM with results that indicated an acute fracture of the right proximal humerus. The resident was transferred to the emergency room (ER) on 10/25/23, when the fracture was identified. The resident returned to the facility on [DATE] at 2:35 AM in a right arm sling along with confirmation of a right proximal humerus fracture. The resident also had an order to follow up with orthopedics. Further review of the facility investigation revealed that the initial report was not submitted to OHCQ (Office of Health Care Quality) until 10/31/23 at 4:45 PM although the injury was identified on 10/25/23. The facility is to report all allegations of abuse, including injuries of unknown source, that resulted in serious bodily injury within 2 hours of the incident. During an interview with the Director Of Nursing (DON) on 09/19/2024 at 9:42 AM, it was revealed that the injury was initially thought to be the result of a previous fall. The DON further stated the team began the investigation of the fall with fracture on 10/25/23. After in-depth chart review, staff interviews, and case review by the Medical Director was completed, the team decided that the injury was possibly an injury of unknown origin. The DON further stated that the injury of unknown origin was initially reported to OHCQ on 10/31/2023. An interview with the Administrator on 09/19/24 at 02:01 PM confirmed that the injury of unknown origin was not reported to OHCQ until 10/31/23 because the team initially thought the injury was the result of a previous fall. 14894 3) A review of a facility reported incident, MD00183710, revealed Resident #2 had a fall on 9/9/22 which was 12 days prior to the date of the incident. The Resident was in an electric wheelchair out front of the building. The resident was moving in the wheelchair and went off of the curb. As a result, the resident hit their head on the concrete. The resident maintained good head alignment and 911 was called. Resident did not lose consciousness. The resident had no change in vision or bleeding. Resident stated they misjudged where the curb was while backing up. The resident returned from the hospital on 9/11/22 at 7:43 PM. Further review of the clinical record failed to find evidence that the state agency had been notified. The Administrator was interviewed on 9/20/24 at 9:51 AM. She was informed of the fall and asked if she reported it. She recounted the incident and acknowledged the fall with injury. Confirmed that it was not reported the Maryland Office of Healthcare Quality.

Based on record review and interview it was determined that the facility failed to ensure a Resident's care plan was revised in a timely manner. This was found to be evident for 1 (Resident # 113) out of 1 Resident reviewed for care plan revisions. The findings include: During a review of Resident #113's medical records conducted on 09/16/24 at 9:51 AM, it was discovered that the resident fell on [DATE], 07/28/23 & 07/31/23. A care plan is a document that outlines the actions and interventions needed to address a person's health or care needs. It can include information about a patient's health conditions, medications, and healthcare providers. Care plans can help ensure that patients receive consistent care. A review of Resident #113's care plan conducted on 09/16/24 at 10:00 AM, revealed the care plan for falls had not been revised to include the resident's falls on 07/14/23, 07/28/23 & 07/31/23. During an interview conducted on 09/16/24 at 12:19 PM, the Regional Clinical Services Manager stated that after she reviewed Resident #113's care plan she determined that the care plan had not been updated to include the falls for 07/14/23, 07/28/23, & 07/31/23.

Based on record review and staff interview it was determined that facility staff failed to provide ADLs (activities of daily living such as, showers, dressing, and toileting) for a resident who was dependent on them for this care. This was evidence for 1 (101) of 2 residents reviewed for ADL care. The findings include: Hospice care focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life. www.nia.nih.gov. During a review of complaint #MD00166118 for Resident #101 it was revealed there were concerns regarding the resident's care needs being provided. On 9/18/24 at 9:54 AM a medical record review for Resident #101 revealed a discharge summary from the hospital that noted the resident was on hospice care when s/he fell and broke his/her arm. The family decided to stop hospice care and send the resident to the facility for therapy. An attending physician note dated 2/7/24 noted the resident had advanced dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life. www.alz.org). A review of the GNA (geriatric nursing assistants) documentation on 9/18/24 at 10:50 AM revealed that the resident had not received a shower the 15 days s/he was at the facility. The resident was scheduled for showers on Mondays and Thursday during the evening shift, however it was marked N/A (not applicable) on 2/5/24 at 10:03 PM, marked n (no) for 2/8/24 at 7:41 PM, and N/A on 2/15/24 at 8:40 PM. Review of the documentation for the resident receiving a bed bath revealed the resident had not been bathed on 2/14/24 and 2/16/24. Review of the documentation for incontinence care reveal care was not provided on 2/6/24 and 2/7/24 on day shift. Review of the documentation for personal hygiene, such as combing his/her hair and oral care, revealed there was no documentation it was provided on 2/6/24, 2/7/24, and 2/11/24 during the day shift and on 2/5/24 during night shift. An interview with GNA #16 revealed that staff were to document the care that was provided. When asked why a staff member would document N/A, she stated that it may be because they did not know. Furthermore, GNA #16 reported the facility had provided the GNAs with training regarding how to document and N/A should not be used. She was unable to recall when this training occurred, but thought it was in 2023. The findings were reviewed with the Director of Nursing (DON) on 9/19/24 at 12:01 PM. He reported that it was acceptable for staff to use N/A if the resident was not available. However, review of the medical record revealed no evidence that the resident had been out of the facility on the days she was marked for N/A for a shower or other care.

Based on interviews and record reviews it was determined that the facility failed to ensure a resident's safety. This was found to be evident for 1 (Resident #36) out of 1 resident's reviewed for quality of care during the re-certification survey. The findings include: During an interview conducted on 09/11/24 at 10:33 AM, Resident #36 stated that on 09/07/24 Geriatric Nursing Assistant (GNA) #8 attempted to assist the resident in the transfer from the bed to the electric wheelchair. The resident stated that the GNA assisted him/her from a lying position to a sitting position to the side of the bed. The resident stated that he/she advised the GNA that the back of his/her legs were not flush against the mattress which was required for a safe transfer from the bed to the wheelchair when using the transfer board. The resident further stated that the GNA went behind the bed from where the resident sat and attempted to pull the resident by his/her pants closer to the mattress. As a result, the resident slid off the bed and onto the floor. According to Centers of Medicare and Medicaid Services (CMS) the Minimum Data Set (MDS) is a powerful tool for implementing standardized assessment and for facilitating care management in nursing homes (NHs). On 09/11/24 at 11:02 AM a review of Resident #36's MDS mobility assessment dated [DATE] revealed the resident required partial/moderate assistance for lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support. On 09/14/24 at 6:19 AM a review of a written statement from GNA #8 stated that I went behind [resident's pronoun] and I was holding the back of his pant to prevent [resident's pronoun] from sliding; [resident's pronoun] also said [resident's pronoun] feel like [resident's pronoun] is sliding down. During an interview conducted on 09/14/24 at 7:30 AM, the Rehabilitation Director #14 stated that Resident #36 required 1 person to assist when using the transfer board. The Rehabilitation Director stated that GNA #8 should not have gone behind the resident to pull the resident closer to the mattress. The expectation for a proper transfer is to stand in front of the resident to perform a safe proper transfer. The Rehabilitation Director further stated that GNA #8 would be provided training on safe and proper transfer of a resident by the therapy department.

Based on record reviews and interviews it was determined that the facility failed to ensure the accuracy of Residents' medical records. This was found to be evident for 3 (Resident # 18, #106, & 99) out of 46 Residents reviewed during the recertification survey. The findings include: 1) During a review of Resident #18's Medication Administration Record (MAR) conducted on 09/09/24 at 11:44 AM revealed an order for Boost VHC two times a day 60 ml (millimeters) PO (oral) with med pass. A continued review of the MAR revealed that the order for BOOST VHC had been documented that Resident #18 had received Boost at 9:00 AM and 9:00 PM for the entire month of August of 2024 and from September 1, 2024, through September 8, 2024. During an interview conducted on 09/09/24 at 12:09 PM, Resident #18 and his/her assigned Geriatric Nursing Assistant (GNA) #5 stated that the Resident disliked Boost and refused it when offered. Both the Resident and the GNA stated that the Resident would only drink chocolate milk with med pas. 2) On 09/16/2024 at 8:09 AM a review of Resident #106's progress notes revealed a nurse's note that stated resident has a poor oral intake, and daughter is concerned [resident's gender pronoun] is deteriorating and would like to request some lab order to check if [resident's gender pronoun] is dehydrated. Based on the daughter [resident's gender pronoun] is not at [resident's gender pronoun] baseline. Primary Care Feedback: New order for BMP [NAME] (tomorrow). The basic metabolic panel (BMP) blood test helps doctors check the body's fluid balance and levels of electrolytes and see how well the kidneys are working. Further review of the resident's progress notes revealed a Change in Condition note. The note stated that the Resident has been declining with PO (oral) intake fluids and food by speech, staff. Daughters aware. BMP (Basic Metabolic Panel) drawn this AM. A review of Resident's 106 medical records did not reveal a BMP lab result. During an interview conducted on 09/16/24 at 11:29 AM, the Nursing Home Administrator (NHA) stated that she reviewed Resident #106's medical records and called the Good Samaritan laboratory company and confirmed that the BMP lab was not drawn. 3) A review of a Facility Reported Incident (FRI) investigation for Resident #99 was conducted on 09/19/24 at 10:30 AM. During the review a Provider's note from Physician #19 stated he provided services to the resident on 06/07/24. The note included details of the FRI and the investigation that was inaccurately based on the timeline of the FRI. During an interview conducted on 09/19/2024 at 11:45 AM, the Director of Nursing (DON) stated that he spoke with Physician #19 who advised the DON that he documented the date of service for Resident #99 in error. The DON stated that the Physician advised him that he provided services to the resident on 06/10/24 not 06/07/24 but signed the note on 06/13/24. The DON was advised that this was a concern for inaccurate medical records.

Based on observation, interviews and medical record review it was determined that the facility failed to follow appropriate infection prevention and control practices. This was found to be evident during the annual recertification survey. The findings include: During the initial tour of the laundry department on 9/9/2024 at 8:25 AM with the Housekeeping Floor Technician (#12) the surveyor observed an employee's personal backpack on the floor underneath the clean laundry folding table in the clean linen area of the laundry room. The surveyor conducted an interview on 9/9/2024 at 8:45 AM with the Housekeeping Floor Technician (#12) and the Laundry Aide (#13) who acknowledged that the employee's personal backpack was on the floor and that the expectation was that employee's personal items were not to be stored in the laundry room. Enhanced Barrier Precautions (EBP) are a set of infection control measures that aim to reduce the spread of multidrug-resistant organisms. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. At 9:50 AM on 9/9/2024 the surveyor conducted infection control rounds on Nursing Unit 1. During the tour, the surveyor observed Resident (#81) and Resident (#89) rooms without an Enhanced Barrier Precautions (EBP) signage posted on the outside of the resident's room door. Enteral tube and feedings are a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation. The state of being fed by a feeding tube is called gavage, enteral feeding or tube feeding. Foley catheter is a thin, flexible tube that drains urine from the bladder into a collection bag. It is a type of indwelling urinary catheter which means it is inserted into the body and left in place. The surveyor at 10:30 AM on 9/9/2024 reviewed the medical records of Residents (#81 and #89). Resident (#81) has physician orders for enteral tube care and feedings, Foley catheter care and Enhanced Barrier Precautions (EBP), and does not have an Enhanced Barrier Precautions (EBP) signage on the outside of the resident's room door. Resident (#89) has physician orders for wound care and Enhanced Barrier Precautions (EBP) and does not have an Enhanced Barrier Precautions (EBP) signage on the outside of the resident's room door. At 11:00 AM on 9/9/2024 the surveyor interviewed the Assistant Director of Nursing/Infection Preventionist (ADON/IP) regarding the policy and procedure for Enhanced Barrier Precautions (EBP). During this interview the ADON/IP stated that all residents with catheters, enteral feedings, wounds, central venous catheters, intravenous lines and tracheostomies should have an Enhanced Barrier Precautions (EBP) signage posted on the resident's room door and have a physician order for Enhanced Barrier Precautions (EBP). The surveyor toured Nursing Unit 1 with the ADON/IP at 11:10 AM on 9/9/2024. The ADON/IP and the surveyor observed that there was not signage posted on the resident's room doors for Residents (#81 and #89) for Enhanced Barrier Precautions (EBP). The ADON/IP stated that he would look into this. At 11:38 AM on 9/9/2024 the ADON/IP and the Regional Clinical Services Manager (RCSM) confirmed on observation with the surveyor that the Enhanced Barrier Precautions (EBP) signage was not posted on the room doors in the appropriate place for Residents (#81 and #89) and that Residents (#81 and #89) have physician orders for Enhanced Barrier Precautions (EBP). On 9/11/2024 at 11:08 AM the surveyor conducted an infection control tour of Nursing Unit 3. The surveyor observed Registered Nurse (#10) who was leaning over the counter eating her lunch in the clean utility room on Nursing Unit 3. In addition, this was observed by the Licensed Practical Nurse (#11) who stated to the Registered Nurse (#10) that she was not to be eating in the clean utility room. The surveyor interviewed the Nursing Unit 3 Unit Manager (#9) and asked her what the expectation was for the nursing staff eating in the clean utility room at 11:15 AM on 9/11/2024. The Unit Manager (#9) stated that nursing staff should not be eating in the clean utility room and that staff should be eating in the employee break room.

Based on observation, staff interview and facility record review it was determined that facility failed to maintain an effective pest control program. This was evident in the facility kitchen and in the facility conference room. The findings include: On the initial tour of the facility's kitchen on 9/3/24 at 8:57 AM with the Certified Food Service Manager (CFSM) the surveyor observed a fly that was flying around near the top shelf of the food storage rack in the dry storage room located in the kitchen. The surveyor interviewed the Certified Food Services Manager (CFSM) at 9:15 AM on 9/3/24 during the kitchen tour, and the CFSM acknowledged that there was a fly that was observed flying around near the top shelf of the food storage rack in the dry storage room. The Certified Food Services Manager (CFSM) stated to the surveyor that the Pest Control Company is scheduled for service and treatment every other week for the facility. At 7:20 AM on 9/18/24 the surveyors observed gnats flying around in the conference room. Additionally, the Nursing Home Administrator (NHA) was observed by the surveyor swatting at a gnat in the conference room when the NHA delivered requested documents to the surveyors. The surveyors received the ORKIN Pest Control Service Reports from the Nursing Home Administrator on 9/12/24 at 9:10 AM. The surveyor reviewed the ORKIIN Pest Control Service Reports from March 2024 through August of 2024. The findings on these reports included the following dates and comments about service: 8/7/2024 - Inspected and treated throughout kitchen area storage area a few units with ants check log for notes check office areas added fly to kitchen due to fly issues; 7/25/2024 - Inspected and treated throughout kitchen area, storage area, break room area, fruit fly issue, and kitchen treated drains unit with ants and with spiders, check logbook for notes; 7/15/24 - Inspected and treated throughout checked all logbook. Treated rooms with ant issues throughout also kitchen has sanitation issues with drains fruit flies underneath sink areas trash cans need to be dumped, and clean drains need to be cleaned; 6/20/2024 - just flying ants around door just treated exterior last week. Told give it time to work, OK with it; 6/13/2024 - Inspected and treated throughout facility checked all logbook monitors no live pest issues to support a couple of Beatles and a few of the monitors and office areas changed out monitors and treated throughout. Wants to get exterior service. Will be there tomorrow morning to treat exterior; 5/31/2024 - Inspected and treated throughout office area break area no live pest issues to report few units with issues. No live and spotted on the interior. Still treated throughout; 4/12/2024 - Inspected and treated throughout kitchen area storage area, brake room area no live pest issues to report roach citing near vending machines put monitors out and treated around vending machines; 3/28/2024 - Inspected and treated throughout entire building checked all logbook only unit for treatment for ants Unit 211 no other issues to report in kitchen area, storage area or office areas; 3/20/2024 - Inspected and treated throughout kitchen area storage area break room area no live test issues to report sanitation issues in the kitchen areas check logbook for residence one unit with roaches 213 treated all around.

Based on observation and staff interview it was determined the facility failed to ensure an effective infection prevention and control program by: 1) failing to ensure that staff utilized personal protective equipment (PPE) in a manner that met minimum standards and minimized risk for infectious spread, and 2) failing to follow infection control guidelines during the laundry process. The noncompliant practices within the facility infection prevention and control program left all residents, staff, and visitors at increased risk for harm during a declared health pandemic and during an active COVID-19 outbreak at the facility. The findings include: On 3/5/20 the Governor of the State of Maryland declared that a state of emergency and catastrophic health emergency exists within the entire state of Maryland related to the spread of COVID-19. On 4/2/2020, The Centers for Medicare & Medicaid Services published COVID-19 Long-Term Care Facility Guidance which provided for the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility. Consistent with the 4/2/2020 CMS guidance, on 6/25/2020, the Centers for Disease Control and Prevention (CDC) published updated guidance (from earlier 3/21/2020, 4/15/2020 and 5/19/2020) entitled Preparing for COVID-19 in Nursing Homes. The CDC directed that healthcare personnel should wear a facemask at all times while they are in the facility. On 10/27/2020 The Maryland Department of Health (MDH) Secretary issued an amended Directive and Order Regarding Nursing Home Matters. The 10/27/2020 Directive and Order, finding it necessary for the prevention and control of 2019 Novel Coronavirus ([DIAGNOSES REDACTED]-CoV-2 or 2019-NCoV or COVID-19), and for the protection of the health and safety of patients, staff, and other individuals in Maryland, hereby authorize and order the following actions for the prevention and control of this infectious and contagious disease under the Governor's Declaration of Catastrophic Health Emergency. This Amended Directive and Order replaces and supersedes the Directives and Orders Regarding Nursing Home Matters, dated October 1, July 24, June 19, April 29, April 24, April 9, and April 5, 2020. 1C. of the order documented, All staff, volunteers, vendors, and visitors when permitted, shall wear the appropriate face covering (e.g., surgical mask, cloth face covering) at all times when they are inside the facility. 1a) Upon entry to the facility on [DATE] at 9:40 AM the surveyors were greeted by Staff #1 who was screening anyone that came into the building for temperature and all signs and symptoms of COVID-19. Staff #1 was wearing a face mask inappropriately as the facemask was below her nostrils. After going to the conference room, the surveyor went back to interview Staff #1 who stated she had COVID-19 and PPE education. During the interview Staff #1's facemask stayed below her nose. 1b) Observation was made during a tour of the facility on 3/3/21 at 10:10 AM of Staff #6 on nursing unit #2 wearing a face shield, however her face mask was below her nose. Staff #6 was interviewed and stated that she had COVID-19 training and education. 1c) Observation was made on 3/3/21 at 1:46 PM of Staff #6 at the receptionist desk by the door to the administrative offices talking to other staff members. Staff #6's mask was below her nostrils. 1d) Observation was made on 3/8/21 at 10:01 AM and at 11:11 AM of Staff #1 sitting at the screener's desk with her mask below her nostrils looking at her cell phone. 1e) Observation was made on 3/8/21 at 11:14 AM of Staff #25 standing at the receptionist desk with her mask below her nose and when the surveyor was approaching the area, Staff #1 yelled Staff #25's name and grabbed her mask to demonstrate to put it up over her nose. 2) CDC (Centers for Disease Control) guidelines for laundry document that, Contaminated textiles and fabrics often contain high numbers of microorganisms from body substances, including blood, skin, stool, urine, vomitus, and other body tissues and fluids. Disease transmission attributed to health-care laundry has involved contaminated fabrics that were handled inappropriately. 2a) Observation was made on 3/3/21 at 10:27 AM of Staff #12 (laundry aide) in the dirty side of the laundry room. Staff #12 was not wearing a clothing protector and began placing soiled laundry in the washing machine. While the surveyor was standing there watching, Staff #12 stopped and placed the clothing protector on. Staff #12's face mask was hovering below her nostrils and was loosely fitted. 2b) During the observation the door that separated the clean laundry side from the soiled laundry side was open and the door from the clean laundry side to the hallway was open. Staff #12 stated that someone came in and opened the door and left it that way. 2c) Continued observation was made on the clean side of the laundry room of a table where clean laundry was folded. There was a word scramble book, Q-tips in a blue case, a highlighter, a tube of hand lotion, a pink sparkled lanyard with a round blue puffy object and keys laying on the top of the table next to the clean linen. There were clean sheets, blankets, towels, washcloths, cookies, and a bottled drink also on the table. There was an industrial fan mounted to the wall on the right side of the room that was caked with dust blowing air throughout the clean side of the laundry room. Underneath the fan were 2 clean linen carts that were not covered. On a separate table were clean bedspreads. Sitting next to the clean bedspreads were employee personal bags, a backpack, and a lunch bag. There were 8 plastic bags with yellow gowns lying on the floor. Also lying on the floor under the table where clean linen was folded were 4 folded clean blankets. Staff #11 walked in the laundry room and started picking up the personal items. Staff #11's mask was below her nostrils. Staff #13 also walked in with her mask below her nostrils. On 3/3/21 at 10:33 AM Staff #10 (the laundry supervisor) walked into the clean side of the laundry room and the surveyor pointed out the caked on dust particles on the fan and asked if the clean laundry bins should have been covered. Staff #10 stated, yes. The surveyor also pointed out the personal items on the table and Staff #10 stated that they did not belong there, and Staff #10 stated that the personal items on the table next to the clean bedspreads did not belong there. The surveyor asked Staff #10 why there were 8 plastic bags with clean yellow gowns sitting on the floor and Staff #10 stated, we have nowhere to store them. The Nursing Home Administrator and Administrative team were advised of the infection control concerns on 3/9/21 at 4:00 PM.

Based on medical record review and staff interview it was determined facility staff failed to immediately notify the physician or Certified Registered Nurse Practitioner (CRNP) when a medication was not available for a resident during end of life care. This was evident for 1 of 10 residents (Resident #11) reviewed during a complaint survey. The findings include: A review of Resident #11's medical record on 3/8/21 at 8:15 AM revealed the resident was admitted to Hospice services on 9/26/19. On 9/30/19 at 11:43 AM CRNP #23 wrote a medication order for [MEDICATION NAME] [MEDICATION NAME] to be administered every 4 hours for increased secretions beginning at 12:00 PM. Review of Resident #11's Medication Administration Record [REDACTED]. A 9/30/19 at 23:47 (11:47 PM) a nurse's note written by RN #24 documented that the resident had rattling in the chest and that RN #24 called the pharmacy 3 times and the pharmacy stated the [MEDICATION NAME] would be delivered that evening between 11:30 PM and midnight. There was no documentation that the physician was notified that the medication had not been administered during that day. On 3/8/21 at 9:38 AM RN #24 stated, I called the pharmacy 3 times and they assured me that the medication was coming, and I proceeded to tell the family that as soon as it comes, I would give it right away. On 3/8/21 at 10:39 AM CRNP #23 was interviewed and asked if she would have expected to be notified that the medication was not available right away and she stated, I would have expected to be notified that the medication was not available if the patient's medical condition warranted it at that time. If I had been aware, we could have given an extra nebulizer treatment. The issue was discussed with the Director of Nursing and the Nursing Home Administrator on 3/8/21.

Based on record review and staff interview, it was determined that the facility staff failed to report an injury of unknown origin to the (OHCQ) Office of Health Care Quality. This was evident for 1 of 10 residents (Resident #9) reviewed during a complaint survey. The findings include: The purpose of a thorough investigation is first to determine if abuse of the resident has occurred. It is the expectation that any allegation of abuse or injury of unknown origin is investigated by the facility and reported to the appropriate agency within 24 hours and the conclusion of the investigation to be reported within 5 days to the appropriate agency (OHCQ) and the Office of Aging (Ombudsman). Review of complaint MD 848 on 3/5/21 at 10:30 AM revealed police responded to the facility on [DATE] for an injured resident. Review of a nursing change in condition report dated 2/24/2020 at 10:30 AM documented that a GNA (geriatric nursing assistant) asked the nurse to look at Resident #9's left foot as there was a bruise that wasn't there 2 days prior when the resident had a shower or the day before when the resident was bathed. The CRNP (certified registered nurse practitioner) was on the unit and examined the resident's toe. The CRNP ordered an x-ray of the left foot to rule out injury due to bruising. X-ray results returned on 2/24/2020 at 19:39 (7:39 PM) documented the resident had a comminuted fracture of the base of the proximal left great toe that appeared acute. The on-call physician was notified and ordered that the resident was non-weight bearing and had an orthopedic follow-up. A 2/25/2020 at 11:07 AM nursing note documented that the Director of Nursing (DON) and a staff nurse met with the police officer to evaluate the bruise to the left great toe. The resident stated he/she thought that he/she bumped it on the w/c wheel. On 3/5/21 at 12:30 PM the surveyor requested a copy of the facility's investigation related to the injury of unknown origin for Resident #9 from the DON. The DON stated she did not think she had an investigation because the resident stated he/she bumped his/her toe on the wheelchair. An interview was conducted with Staff #22 on 3/5/21 at 12:50 PM. Staff #22 stated the resident was declining with dementia. Staff #22 stated one minute the resident's behaviors were fine and the next minute the resident would curse at staff and was very moody. Staff #22 stated the resident was alert and oriented to self and sometimes place. Staff #22 was asked if she would have done an investigation since the resident had dementia and no one knew how the resident hurt the big toe. Staff #22 stated she did an investigation and turned it into the DON. Staff #22 stated, I interviewed staff. The day before the resident did not have any bruising. She stated, I asked what happened and the resident stated he/she bumped it on the wheelchair. He/she smiled when I asked if he/she bumped it trying to get into bed. Staff #22 stated the police officer did his part of the investigation. Staff #22 stated, a bruise of unknown origin, you have to do an investigation as to the cause. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . A 2/24/2020 physician's note documented, unable to provide due to cognitive impairment. A 1/27/2020 physician's history and physical documented, poor historian. The Maryland Medicaid Assistance Eligibility form #3871B documented the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident also had 2 care plans related to impaired memory and/or cognition r/t neurological disorder (dementia) AEB (as evidenced by) unable to recall short term events that was created on 2/3/2020 and a second care plan, impaired mobility r/t [CONDITION(S)]. On 3/5/21 at 10:38 AM the Nursing Home Administrator (NHA) and Staff #29 (Corporate Representative) informed the surveyor that they could not find a self-report and that they probably would not submit one because the resident had a BIMS (Brief Interview of Mental Status) of 14 (indicating resident was cognitively intact) and said he/she thought he/she hit the toe on the wheelchair. They were then asked why the police were notified. Staff #29 replied that whoever called the police probably thought it may be abusive but when the police showed up and asked the resident what happened the resident said he/she thought he/she hit the toe. The NHA was asked if an investigation was done and the NHA stated she could not remember the incident and would have to check. Staff #29 also stated he thought the daughter was involved and they were wondering if something was going on there. Staff #29 was then asked, well if you thought there was some abuse with the daughter wouldn't you still report it and then find the answers through an investigation? Staff #29 said, let us see if we can find the investigation. Both the NHA and Staff #29 were informed that Staff #22 stated she did an investigation and turned it into the DON. On 3/9/21 at 4:00 PM the concern was discussed with the NHA and Staff #22 after they were unable to produce an investigation.

Based on medical record review and staff interview it was determined the facility failed to keep complete and accurate medical records by failing to document that a resident had been suctioned during end of life care. This was evident for 1 of 10 residents (Resident #11) reviewed during a complaint survey. The findings include: A review of Resident #11's medical record on 3/8/21 at 8:15 AM revealed the resident was admitted to Hospice services on 9/26/19. On 9/30/19 at 11:43 AM CRNP #23 wrote a medication order for [MEDICATION NAME] [MEDICATION NAME] to be administered every 4 hours for increased secretions beginning at 12:00 PM. Review of Resident #11's Medication Administration Record [REDACTED]. A 9/30/19 at 23:47 (11:47 PM) nurse's note written by RN #24 documented that the resident had rattling in the chest and that RN #24 called the pharmacy 3 times and the pharmacy stated the [MEDICATION NAME] would be delivered that evening between 11:30 PM and midnight. An interview was conducted with Staff #22 (unit manager) on 3/8/21 at 9:21 AM who stated that RN #24 was waiting for the pharmacy to deliver the medication. Staff #22 stated that while they were waiting for the medication, they had the suction machine set up and had been suctioning excess secretions from Resident #11. On 3/8/21 at 9:38 AM RN #24 stated, I called the pharmacy 3 times and they assured me that the medication was coming, and I proceeded to tell the family that as soon as it comes, I would give it right away. RN #24 stated, I kept up with his/her secretions because I did a lot of mouth care. RN #24 stated, The family was there so as requested I suctioned him/her. I suctioned when they requested. Review of all nursing notes, resident evaluations and the treatment and Medication Administration Record [REDACTED]. The issue was discussed with the Director of Nursing and the Nursing Home Administrator on 3/8/21.

Based on observations, review of daily staffing records, and staff interview it was determined that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses(LPN), and Certified Geriatric Nurse Aides (GNA) per shift. This was evident on 2 of 3 units observed. The findings include. A tour of the nursing units with the Director of Nursing (DON) and Staff #14 (Regional Nurse) on 3/3/21 at 11:03 AM revealed that staffing boards were not complete, accurate and up to date. On the Unit 3 nursing unit there were no staffing hours displayed and no paper copy of the staffing. On the Unit 2 nursing unit the date 3/2/21 was displayed above the white dry erase board on a staffing paper that was sideways, unreadable, and out of view of any resident or visitor, especially if the resident or visitor was in a wheelchair. A paper copy of the hours was taped to the front of the nurse's station, however when the nurse was asked about the paper, she took it off the front of the nurse's station and started filling in the nurses' names. There were no nurse's names or hours on the sheet prior to the surveyor and DON walking up to the nurse's station.

Based on review of a complaint, medical record review, and staff and responsible party interviews it was determined the facility failed to safeguard protected health information when facility staff erroneously included health information belonging to Resident #6 along with documents intended for a medical appointment for Resident #4. This had the potential to affect all the residents in the facility. The findings include: Review of complaint MD 701 on 9/7/19 revealed an allegation that the complainant received health information from another resident's (Resident #6) medical records upon receiving documents for Resident #4's medical appointment. The document received in error contained some demographic and health information. During an interview with the surveyor on 10/8/19 at 1:56 PM the complainant confirmed that s/he received documents needed for Resident #4's medical appointment and later realized that staff erroneously included some of Resident #6's health information. During an interview with the surveyor on 10/8/19 at 2:00 PM the Administrator revealed she/he was not aware that the error occurred. The Administrator took immediate action to correct the error, including notification to Resident #6 and responsible party and re-education for staff regarding safeguarding protected health information.

Based on record review and interview with staff it was determined that the facility failed to offer twice weekly showers as scheduled or offer any showers. This was evident for 1 of 2 residents (Resident #235) reviewed for choices in the investigative stage of the survey. The findings include: Review of complaint MD 959 on 8/22/19 revealed that the resident had not been getting showers. During an interview with the resident on 8/22/19, the resident revealed that he/she liked to take showers, the resident further revealed that the warm showers are very relaxing. Review of the physician orders [REDACTED]. Further review of the medical records revealed that the resident has an extensive stomach wound. During an interview with the Wound Nurse #11, it was revealed that taking showers was not contraindicated. Review of the shower log from (MONTH) 8-22, 2019 revealed the facility documented that the resident only received 1 shower on 8/19/19. Further review of the log failed to reveal any documentation indicating that the resident refused showers. During an interview with the Regional Clinical Manager (Staff #2) on 8/22/19 the surveyor asked for any additional documentation showing that the resident received showers. Staff #2 revealed that she went through the resident's records and spoke with the Geriatric Nursing Assistant, but she was unable to provide any information or documentation indicating that the resident was receiving showers on Wednesday and Saturday as ordered. She further revealed that the resident would be receiving showers on her/his scheduled days. All findings discussed in depth with the Administrator and Director of Nursing at the survey exit on 8/22/19.

Based on complaint review, reviews of a closed medical record and staff interview, it was determined that the facility staff failed to immediately notify a resident's physician and resident's representative (RP) with a continued significant weight loss prior to discharging the resident home. This was evident for 1 of 42 residents (Resident #185) reviewed during the annual recertification survey. The findings include: Review of complaint MD 384 on 08/19/19 revealed an allegation that Resident #185 suffered a steady weight loss during his/her stay in the facility. In an interview with the complainant on 08/19/19 9:07 AM, the complainant alleged that Resident #185 lost weight and the staff did not treat Resident #185 for the weight loss before discharging Resident #185 home. Review of Resident #185's closed medical record revealed Resident #185 was admitted to the facility on [DATE] after a fall in which Resident #185 suffered a fractured right leg and spine. Resident #185 required a neck brace and a leg splint when discharged from the hospital. Resident #185 was admitted to the facility with a weight of 134.5 pounds which included the weight of the brace and splint. On 05/06/19, Resident #185 was seen by the trauma surgeon and the leg splint was discontinued at that time. Resident #185 weighed 118.2 pounds on 05/06/19. Review of Resident #185's closed medical record revealed the following weights in pounds (lbs): 05/08 19 - 118.0 lbs. 05/13/19 - 113.0 lbs. 05/15/19 - 112.6 lbs. 05/20/19 - 108.0 lbs. 05/22/19 - 107.2 lbs. 05/27/19 - 107.4 lbs. 06/03/19 - 106.2 lbs. 06/10/19 - 100.0 lbs. 06/17/19 - 96.8 lbs. 06/18/19 - 95.8 lbs. On 05/15/19, Resident #185's physician gave orders instructing the nursing staff to administer the supplement, Ensure Clear, to be given two times a day at breakfast and dinner. On 05/22/19, the facility Nurse Practitioner (CRNP) #22 followed-up and reassessed Resident #185 for weight loss. The CRNP ordered a magic cup to be given to Resident #185 three times a day with meals. Review of Resident #185's supplement administration and amounts consumed for (MONTH) 2019 show Resident #185 was accepting the supplements and consistently consuming 100% of each supplement administered. Review of Resident #185's supplement administration and amounts consumed for (MONTH) 2019 revealed Resident #185 was accepting approximately 50% of the magic cup supplement and 50 to 100% of the Ensure Clear supplements in (MONTH) 2019. Review of Resident #185's care plans revealed a care plan specific for: Inadequate oral food/beverage intake care plan which was initiated on 04/23/19. The goal of the care plan was that Resident #185 would consume 75% of meals, supplements thru review date. Nursing interventions included: maintain a regular diet with a dysphagia 2 texture and give Resident #185 thin liquids, administer Ensure Plus twice a day and magic cup with meals, monitor meal intake and document, weigh Resident #185 per facility protocol, monitor labs as needed, give feeding assistance and supervision. Review of Resident #185's (MONTH) 2019 breakfast, lunch, and dinner meal percentages revealed the nursing staff were documenting progressive declines in food intake thru (MONTH) 2019. From 06/11/19 thru 06/18/19, the nursing staff were frequently documenting Resident #185 would either refuse his/her meals or would only consume 0-25%. On 06/17/19, the nursing staff documented Resident #185 weighed 96.8 pounds. This is a 21.2 pound weight loss (17.9%) from 05/08/19. On 06/18/19, the nursing staff documented Resident #185 weighed 95.8 pounds which was a 22.2 pound weight loss (18.8%) from 05/10/19. A weight loss of 21.1 pounds (17.9%) on 06/17/19 and loss of 22.2 pounds (18.8%) on 06/18/19 from the 05/10/19 weight of 118 pounds was considered a significant weight loss. In an interview with the facility Dietician #21 on 08/22/19 at 8:53 AM, the facility dietician stated that s/he never received a call regarding Resident #185's weight loss on 06/17/19 or 06/18/19. The facility dietician stated that another dietician attempted to see Resident #185 on 06/11/19 but the staff were providing care and that dietician never returned for a follow-up assessment or conversation. In an interview with the facility CRNP #22 on 08/22/19 at 10:56 AM, the facility CRNP stated that s/he did not receive a call from the nursing staff regarding Resident #185's weight loss on 06/17/19 or 06/18/19. Review of Resident #185's (MONTH) 2019 nursing notes failed to reveal any documentation the nursing staff notified Resident #185's physician or Resident #185's representative regarding the significant weight loss identified on 06/17/19 or 06/18/19. The concern regarding the failure to notify the physician and the RP of the significant weight loss was discussed with Administrator and the Director of Nursing at the survey exit on 8/22/19.

Based upon medical record review, staff interview and a review of institutional policy and procedures, it was determined that facility staff failed to respond and intervene to a resident's emergent life threatening change in condition, delayed the provision of life sustaining interventions and failed to appropriately identify and respond to resident's code status. Code status refers to the level of medical interventions a patient wishes to have started if their heart or breathing stops. The failure of the facility to respond and intervene to Resident #70's emergent life threatening change in condition, the delay in the provision of life sustaining interventions and the failure of the facility to appropriately identify and respond to the resident's code status placed this resident and other residents at risk of potential adverse consequences. As a result a condition of Immediate Jeopardy was declared on [DATE] at 5:15 PM. The Nursing Home Administrator and the Director of Nursing were informed of the need to prepare and implement an action plan to remove the condition of Immediate Jeopardy. On [DATE] at 8:50 PM the Immediate Jeopardy was abated, as the facility put in place a plan to remove immediacy. The abatement plan includes the following measures: a) The Regional Clincal Services Manager reviewed medical records for residents that expired in the facility between [DATE] through [DATE] to ensure CPR was initiated if the MOLST form indicated a full code. No other resident issues were identified. The Director of Nursing (DON) will be responsible for this process. b) The following training will occur for licensed facility and contract nurses: i. Properly assess, respond and intervene to a resident's emergent life threatening change in condition, provide for timely life sustaining interventions and to properly identify and respond to a resident's code status. Training shall be provided by the DON, Nursing Management, Regional Nurses or Future Care Education Department Trainers. ii. The Future Care Education Department Trainer(s) has re-educated GNA's (Geriatric Nursing Assistants) regarding responsibility to report to Unit Managers/Shift Supervisor if they feel nurse is not responding appropriately to concerns about a resident. The DON shall be responsible for this process. c) The Medical Director or Nursing Administration will conduct a 100% daily review of medical records for any resident who expires in the facility to ensure staff initiated CPR if the MOLST form indicates a full code. The results of these audits will be submitted to the Performance Improvement Committee for further review and recommendation. This was evident for 1 of 39 residents (Resident #70) reviewed during Stage 2 of the annual Quality Indicator Survey. The findings include: Resident #70 was admitted on [DATE] with a medical history significant for Type 2 Diabetes, [MEDICAL CONDITION], [DIAGNOSES REDACTED] Fibrillation (irregular heart rate), [MEDICAL CONDITIONS] (a condition that makes it difficult to breath) with dependence on home oxygen, End Stage [MEDICAL CONDITION] (kidney disease), Hypertension (high blood pressure) and [MEDICAL CONDITIONS] related to Orthostatic [MEDICAL CONDITION] (a drop in blood pressure due to position changes). A review of the resident's medical record reveals a MOLST (Maryland Medical Orders for Life Sustaining Treatment) form signed by NP #1 on [DATE]. The MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. The MOLST states that the resident requested that CPR be attempted if cardiac and/or [MEDICAL CONDITION] arrest occurs. This is to include all medical efforts that are indicated during arrest, including arterial ventilation and efforts to restore and/or stabilize cardiopulmonary function. Resident #70's MOLST indicates that he/she is a Full Code. A Full Code is a designation that instructs health care providers to intercede immediately in the event that a patient's heart or breathing stops. Review of the medical record on [DATE] at 9:00 AM reveals the following Interdisciplinary Notes penned by LPN #1 ( Licensed Practical Nurse ) and entered into the resident record on [DATE] at 10:08:57 AM: At approx. 4:00 AM GNA (Geriatric Nursing Assistant) assigned reported that it appears resident stopped breathing. After checking resident's apical pulse, resident started breathing again, breathing is faster and deeper then return to normal. EMediCall MD to make him/her aware at 4:23 AM. Supervisor on duty made aware. At 4:48 AM resident noted with no breathing. Stat was called. CPR started. 911 called while CPR in progress. AED on advice 1 shock at 5:20 AM. (An automated external defibrillator (AED) is a portable device that checks the heart rhythm and can send an electric shock to the heart to try to restore a normal rhythm.) At 5:41 AM paramedics pronounced resident dead. Post mortem care provided to res. R/P made aware. Awaiting MD return call. On [DATE] the facility eMediCall log documents a message sent at 4:23 AM by LPN # 1 to Physician #1 with an Urgency status of: Emergency. The text states the following: At approx. 4:00 AM, Resident stopped breathing in his/her sleep. No apical pulse detected. Has refused going to [MEDICAL TREATMENT]. Skin is warm to touch. Further review of the eMediCall Log has determined that receipt of the message was not acknowledged by Physician # 1, the intended recipient. On [DATE] at 11:22 AM an interview was conducted with LPN # 1. LPN#1 reports that around 4:00 AM the GNA told me that it looked like Resident #70 was not breathing so I went in and called the resident's name. His/her eyes and mouth were moving. I checked the resident's apical pulse and it was so faint I didn't get it. It was the apical pulse that worried me and made me call the doctor. The resident's oxygen level was 90. I wasn't clear if the resident was breathing. I called the doctor with the computer and the phone. I kept calling and calling. I never spoke to the doctor. I went to the supervisor because I couldn't reach the doctor. LPN #1 affirms that CPR was not initiated nor was 911 called until after 5:00 AM. On [DATE], a review of the [DATE] facility phone log captures phone calls originating from the Unit 2 Charting room to Physician #1 at 4:15:25 AM and 4:48:55 AM. LPN # 1 was unable to provide a consistent timeline of transpired events. An interview with the DON was conducted on [DATE] at 1:27 PM in which DON ( Director of Nursing) stated a root cause analysis was initiated on [DATE] and that in reference to the actions of LPN #1 timing, interventions and steps were not clear because the LPN's statements were inconsistent. Clarification interviews were had with other staff members to corroborate details. An interview with GNA #1 was conducted on [DATE] at 12:55 PM. When asked to recount the events of [DATE] the GNA's response was as follows: I came in at 11:05 PM and did a walkthrough of my residents. I checked on Resident #70 and he/she was ok. Around 12:00 Midnight I checked on the resident and he/she didn't look too good. I told LNP#1 because maybe he/she may want to check his/her blood sugar. LPN #1 told me that the family wanted Resident #70 to die in peace. I didn't know if that was true or not but I thought he/she knew something I didn't know. Around 4:00 AM I went into the resident's room and didn't think the resident was breathing. I told GNA #2 and he/she came into the room with me. GNA #2 checked his/her pulse and said 'yes, he/she is gone. ' I went to report it to LPN #1. LPN #1 went in and said yes, he/she is gone . I told LPN #1 that the resident was a full code. LPN #1 said the resident was not a full code. I asked LPN #1 if I should page the other nurses and LPN #1 said no. An interview with GNA #2 was conducted on [DATE] at 12:06 PM. When asked to recount the events of [DATE] GNA #2 stated Around 4:00 AM GNA #1 came to me and said she/he thought Resident #70 had died . We ran to the room. The resident's eyes were open. I put my finger under his/her nose and didn't feel his/her breathing. We ran and told LPN #1. LPN #1 entered the room and checked Resident #70's heart with the stethoscope. LPN #1 said the resident was gone . GNA #1 told LPN #1 that Resident #70 was a full code. I also said that the resident was a full code. LPN #1 said the resident was not a Full Code and went back to the nurse's station. We kept watching the clock and waiting for LPN #1 to give us directions or to go get the supervisor. An interview with RN (Registered Nurse) #1 was conducted on [DATE] at 2:26 PM. Of the events RN #1 stated LPN #1 came to me about 5:00 AM to tell me the resident was not breathing. I asked the resident's code status and LPN #1 stated that the resident was a Full Code. I went to the unit, checked the resident's chart and confirmed the code status. We entered the room and the resident was in bed, without chest rise and with no pulse. LPN #2 initiated CPR and LPN #1 called 911. On [DATE] a review of the [DATE] facility phone log captures a phone call originating from the Unit 2 Nurse Station 2 to 911 at 5:09:29 AM. Continued record review on [DATE] at 12:00 PM reveals a shift report from RN #1 was emailed to the DON on [DATE] at 6:35 AM reflects the following message LPN #1 came to me around 5:00 AM to tell me Resident #70 had stopped breathing. I called for all nurses stat to unit 2, checked patient's chart, and it was noted that he/she was a full code. CPR was started, 911 was called, AED was used patient got 1 shock at 5:20 AM, CPR continued until 911 came and they took over. Patient was pronounced by EMS. AED placed by your door, as the AED pads were used. In an interview with LPN #2 conducted on January, 2017 at 11:54 AM, LPN #2 stated LPN #1 came up behind me after 5:00 AM when I was passing meds. LPN #1 asked for a doctor's phone number. I knew the doctor was no longer working here so I told LPN #1 to go to RN #1. The next thing I knew a code was called. I ran to the room and initiated CPR. I ' m not sure of the exact time but it was after 5:00 AM because I started passing meds at 5:00 AM. On [DATE] a review was conducted of the Corporate CPR protocol which states that the purpose of the policy is to follow the expressed wishes of the resident or the healthcare decision maker and that the expressed wishes of the resident or the healthcare decision maker, if the resident has been incapable of expressing his/her wishes will be followed in the event of a sudden cardiopulmonary arrest. The facility's failure to respond and intervene in a resident ' s emergent change of condition led to a delay in the provision of life sustaining and life-saving treatment. The facility also failed to identify and respond to resident's code status.