Every finding on record at Future Care Old Court

Based on record review and staff interviews, it was determined that the facility failed to ensure staff received ongoing Quality Assurance and Performance Improvement (QAPI) training. This deficient practice was evident for 4 of 5 employee files reviewed during the annual survey.The findings include:On 03/13/2026 at 10:45 AM, a review of Geriatric Nursing Assistant (GNA) #4, GNA #13, GNA #14 and GNA #15 employee files failed to show evidence of ongoing QAPI training following initial hire. The GNA hire dates ranged from 2010 through 2025, indicating continued employment without documented QAPI training.During an interview on 03/13/2026, with the Administrator, the surveyor inquired about the facility's QAPI training for staff. The Administrator stated the facility conducts performance improvement town hall meetings; however, the meetings do not include required ongoing QAPI training. The surveyor informed the Administrator of the missing QAPI training for GNA #4, GNA #13, GNA #14 and GNA #15.On 03/17/2026 at 9:27 AM, the Administrator acknowledged that ongoing QAPI training had not been provided and was unable to provide documentation indicating that training was conducted for the identified staff members.

Based on observation and interviews with facility staff, it was determined that the facility failed to a keep a sanitary environment in the kitchen. This was evident during the initial observation of the kitchen during the annual re-certification survey. The findings include: Observation on 03/10/2026 at 8:05 AM: During the initial tour of the kitchen with Staff #9, the Dietary Manager, the following conditions were observed: At least five torn areas on the floor were noted, with the underlying red brick exposed. In the dishwashing area, the floor was torn in several places, and the red brick underneath was exposed. A rusted bait trap was observed under the triple sink. Chipped flooring was noted in the corner by the walk-in freezer and the walk-in refrigerator. The baseboard was detached from the walls in the dishwasher area. The baseboard behind the ice machine was chipped and detached from the wall separating the walk-in freezer and walk-in refrigerator. The ceiling above the walk-in refrigerator, adjacent to the ice machine, showed peeling with visible light-colored large pieces of paint hanging down. The ceiling in the remaining kitchen area is black. Follow-up observation and interview on 03/11/2026 at 11:57 AM: The issues noted above were reviewed with the Nursing Home Administrator (NHA) and Staff #8, the Maintenance Director. The following specific conditions were confirmed: At least five torn areas on the floor were observed, with the underlying red brick exposed. In the dishwashing area, the floor was torn in several places, and the red brick underneath was exposed. The rusted bait trap remained under the triple sink. The chipped flooring was confirmed in the corner by the walk-in freezer and the walk-in refrigerator. The detached baseboards were confirmed in the dishwasher area. The chipped and detached baseboard behind the ice machine, between the walk-in freezer and walk-in refrigerator, was confirmed. The peeling paint on the ceiling above the walk-in refrigerator by the ice machine, with visible large pieces of light-colored paint hanging down, was confirmed. The ceiling in the entire kitchen remains black. The NHA and Staff #8 verbalized understanding that the issues listed above represented conditions of concern for facility sanitation.

Based on interviews and administrative record review, it was determined that the facility failed to provide all geriatric nursing assistants (GNA) with the required annual dementia training. This deficient practice was evident for 32 out of 43 GNA's reviewed during the survey. The findings include: On 12/09/2024 at 8:59 AM, review of employee records for GNA #27, GNA #28, GNA #29, and GNA #31 failed to show evidence of required annual dementia training. During an interview with the Director of Nursing (DON) #2 on 12/09/24 at 10:43 AM she explained that annual competency for GNA includes a skills fair. The fair covers education on dementia care, abuse prevention and reporting, resident rights, infection control, and additional in-services to address any concerns that may have arisen during the year. The DON #2 reported that the most recent skills fair was held on 6/27/24. On 12/9/24 at 11:48 AM, a review of the in-service dementia training provided during the GNA annual skills fair, compared to the facility's current list of active GNA's, revealed that only 11 out of 43 employees received dementia training in 2024. Both the Administrator #1 and DON #2 were informed of the findings and the Administrator #1 explained that the facility recently transitioned from Relias to HealthStream training and would attempt to obtain the GNA dementia training records from Health Stream. On 12/10/24 at 7:38 AM, during a follow-up with the Administrator #1 regarding GNA Dementia training, the Administrator stated that a staff member was working on obtaining online dementia training for 2024. The Administrator #1 also acknowledged that the facility was not fully compliant with GNA training requirements for 2024. On 12/11/24 at 7:56 AM, the Corporate Regional Nurse #8 provided the surveyor with evidence that dementia in-service training was conducted on 12/10/24. On 12/12/24 at 7:29 AM, the Administrator #1 provided the surveyor with evidence that dementia in-service training was conducted on 12/11/24

Based on the kitchen tour and staff interview, it was determined that the facility failed to ensure that stored food items were properly labeled and dated. This deficient practice has the potential to affect all residents in the facility. The Findings Include: On 12/04/24 at 07:45 AM, during the initial kitchen tour with the Certified Dietary Manager (Staff#10), the following deficiencies were observed: 1. The walk-in refrigerator revealed a stand-alone plastic bag of chicken breast, approximately 20 frozen pieces, and a plastic bag of link sausages that did not have labels and were not dated. 2. A bottle of honey was found in the dry storage area with a prep date of 11/26/2024 and a used date of 12/03/2024. Staff #10 stated, honey is good for 3 years. 3. The dry food section had a container of graham crackers in individual packets that were not dated. An original box of graham crackers had a date. However, there was no way to identify which box the individual crackers came from. 4. Two of one gallon bottles of Cattlemen's BBQ Sauce: one had a sticker label with prep on 11/30/2024 and used by 12/05/2024. The other had a sticker label with prep on 11/16/2024 and used by 11/23/2024. 5. A one gallon of Soy Sauce had a label with a prep date of 11/16/2024 and used by 11/22/2024. 6. A gallon bottle of Worcestershire Sauce had a label with a prep date of 10/29/2024 and used by 11/29/2024. During the tour, Staff #10 was interviewed about the findings. Staff #10 acknowledged that staff were inconsistent in labeling and dating food items, which warrants further staff training. On 12/12/2024 at 09:13 AM, the facility provided the surveyor with the food storage policy. There was no mention of dating or labeling of food written in this policy. The surveyor was not provided a copy of the facility policy that guides the labeling and dating of food items. On 12/12/24 at 08:35 AM, the surveyor discussed these concerns with the Nursing Home Administrator.

Based on a review of a Facility Reported Incident, resident interview, and staff interviews, it was determined that the facility failed to ensure that the agency Geriatric Nursing Assistant (GNA) had received the annual abuse education required to work with long-term care residents. This was evident for 1 (staff #32) of 3 GNAs reviewed for abuse education during the survey. The findings included: During an interview on 12/05/24 at 12:58 PM with Resident #23, the resident's daughter stated there had been an incident of missing checks. Upon further questioning, Resident #23's daughter stated that a GNA had stolen and cashed two checks, but the funds were reimbursed. On 12/06/24 at 11:50 AM, the Surveyor requested the Facility Reported Incident for the above incident. On 12/06/2024 at 12:09 PM, a review of the facility-reported incident, MD00183120, reported on 11/16/2022, revealed an allegation of misappropriation of funds. Resident #23 reported that she/he did not have his/her checkbook. Resident #23's daughter reported that two checks had cleared Resident #23's account, one for $600 and another for $400. Resident #23's bank confirmed that the name on the two checks was GNA #32. The facility confirmed that GNA#32 worked as an agency GNA on 11/16/2022 on 7-3 and 3-11shifts. The investigation conducted by the facility results determined that two checks totaling $1000 were written to GNA #32 and were cashed. Resident #23 s bank blocked her/his account and reimbursed Resident #23. On 12/06/2024 at 2:16 PM, the Nursing Home Administrator (NHA) was interviewed. The NHA stated that the facility conducted a thorough investigation and provided the information to the staffing agency. In addition, the NHA stated that prior to agency staff working at the facility, the facility staffing coordinator would look up agency staff training and background checks on the agency's portal. The facility staffing coordinator (Staff #22) was interviewed on 12/06/2024 at 2:30 PM. She stated that the agency staff's credentials, background checks, and training were on the agency's portal. Staff #22 provided a printout of GNA# 32's abuse training, signed and dated 5/19/2021. It was noted that the GNA abuse training was overdue for the annual education requirement. The surveyor requested any documentation to support GNA #32, who received abuse, neglect, and misappropriation training annually. However, the facility staff confirmed that GNA #22 did not have additional training records prior to the above incident. On 12/12/2024, NHA was made aware that this was a concern.

Based on observation and interview, it was determined that the facility failed to ensure residents were treated with respect and dignity while assisting residents with meals. This was evident for 1 (Resident #283) of 1 resident observed being fed by staff. The findings include: On 12/10/24 at 1:00 PM, the surveyor observed Geriatric Nursing Assistant (GNA, Staff #46) standing over Resident #283 when feeding the resident. On 12/10/24 at 1:06 PM, an interview with agency GNA #46 revealed that she was agency staff and she was not aware that staff should not stand when feeding residents. On 12/11/24 at 8:43 AM, an interview with agency GNA (Staff #45) revealed that she was agency staff and she was not aware that staff should not stand when feeding residents. On 12/11/24 at 12:43 PM, an interview with the Staffing Coordinator (Staff #22) and the Nursing Home Administrator (NHA, Staff #1) revealed that agency GNAs are not educated on maintaining resident dignity pertaining to feeding upon working at the facility. Staff #22 indicated that GNA's are educated on such skills in school to obtain their GNA license and should be using those skills at the facility. On 12/11/24 at 1:51 PM, the surveyor reviewed the concern with the NHA.

Based on reviews of a facility reported incident, interviews, and record review, it was determined that a staff member had removed money from a resident's account without permission. This was evident for 1 of 36 facility reported incidents reviewed during an annual recertification survey. The findings include: On 12/06/2024 at 12:09 PM, a review of the facility-reported incident, MD00183120, reported on 11/16/2022, revealed an allegation of misappropriation of funds. Resident #23 reported that she/he did not have his/her checkbook. Resident #23's daughter reported that two checks had cleared Resident #23's account, one for $600 and another for $400. Resident #23's bank confirmed that the name on the two checks was Geriatric Nursing Assistant (GNA) #32. The facility confirmed that GNA#32 worked as an agency GNA on 11/16/2022 on 7-3 and 3-11 shifts. The investigation conducted by the facility determined that two checks totaling $1000 were written to GNA #32 and were cashed. Resident #23's bank blocked her/his account and reimbursed Resident #23. The Nursing Home Administrator (NHA) was interviewed on 12/06/2024 at 2:16 PM. The NHA stated that the facility conducted a thorough investigation and provided the information to the staffing agency. On 12/06/2024 at 02:30 PM, an interview was conducted with the staffing coordinator (Staff # 22), who stated that the background checks and training are reviewed on the agency's portal. When asked about the most recent abuse training for GNA #32, she stated that GNA#32 was a DNR Do Not Return to the facility but was able to provide a copy of the training. GNA #32's abuse training was dated 5/19/2021, which was outdated at the time of the incident. On 12/12/24 at 08:30 AM, the surveyor discussed concerns with NHA concerning the outdated abuse training and the failure to protect Resident #23 from misappropriation of resident property.

Based on record review and interview with staff, it was determined that the facility failed to timely report an allegation of abuse to the State Agency, the Office of Health Care Quality (OHCQ), immediately but not later than 2 hours after the allegation of abuse was made. This was evident for 2 (Resident #34 and #147) out of 15 residents investigated for abuse during the survey. The findings include: 1) On 12/5/2024 at 1:45PM, the Surveyor reported an allegation of abuse which involved Resident #34 to the Nursing Home Administrator (NHA) #1. On 12/6/2024 at 11:38AM, the NHA #1 provided the Surveyor with the Facility Reported Incident (FRI) initial report form for the abuse investigation. During a review of the FRI document, the Surveyor discovered that the report was completed on 12/6/2024 at 9:45AM and not within the two-hour timeframe. During an interview with NHA #1 and Regional Nurse #3 on 12//6/2024 at 1:40PM, the Surveyor confirmed that the FRI initial report form was not completed within the two-hour timeframe of the abuse allegation. 42863 2) On 12.06.24 at 2:00 PM the surveyor reviewed MD00202200, a facility reported incident (FRI) for Resident #147 related to alleged employee to resident sexual abuse. Per the documentation in the FRI, the facility staff became aware of the incident on 02.04.24 at 9:50 PM. Also, per the facility report the Administrator, Staff #2 was notified of the incident on 02.04.24 at 10 PM by the former director of nursing, (DON) #38. Resident #147 reported to the staff that he/she felt sharp pain near [his/her] vagina and alleged that [Staff # 34] maybe put his finger in there during incontinence care. The Resident had a Brief Interview for Mental Status (BIMS) score of 15. According to the FRI there were no facility staff witnesses, and Resident #147 was not found to have any injuries at the time of the incident on 02.04.24 when examined by a female nurse. On 12.07.24 at 2:30 PM the surveyor reviewed the hard copy of the facility incident report folder provided by the facility. The administrator, Staff #1 documented in the initial facility report was submitted on 02.05.24 at 11:30 PM which was more than 2 hours after the knowledge by staff of the abuse allegation. Additionally, the administrator documented that the resident representative and the medical director were notified on 02.05.24. On 12.09.24 at 1:40 PM the DON and Administrator were advised that the surveyor required a copy of the full FRI documents related to MD00202200. The facility had determined the allegations were not substantiated per the documentation in the hard copy FRI. The surveyor discussed the concern regarding the timely submission of the FRI to the OHCQ department. On 12.12.24 at 1:00 PM the surveyor discussed the concerns again with the Administrator regarding the late submission of the initial facility incident report.

Based on record review and interview with residents and staff, it was determined that the facility failed to develop and implement a comprehensive care plan for residents. This was evident for 1 (Resident #103) out of 61 residents reviewed during survey. The findings include: A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage a resident's care. On 12/9/2024 at 7:00AM, during an interview with Geriatric Nursing Assistant (GNA) #55, the Surveyor was informed that residents are scheduled to have two showers a week and showers are usually given during the 7AM-3PM shift or 3PM-11PM shift. During review of Resident #103's task care report for November 2024 and December 2024 on 12/9/2024 at 1:30PM, the Surveyor discovered a GNA task for showers/tub bath on Mondays and Thursdays during the 3pm-11pm shift. Further review revealed documentation of N, the resident did not receive a shower or RR, the resident refused a shower on Mondays and Thursdays from November through December 2024 On 12/10/2024 at 10:25AM, the Surveyor reviewed the shower sheet binder at the 1st floor nurses station. The Surveyor did not observe any shower sheets for Resident #103 in the binder. The Surveyor requested Resident #103's shower sheets for November 2024 and December 2024. On 12/10/2024 at 2:10PM, a review of Resident #103's shower sheets revealed the resident refused a shower on Wednesday 11/6/2024, Wednesday 11/13/2024, Wednesday 11/20/2024, Wednesday 11/27/2024, and Wednesday 12/4/2024. On 12/10/2024 at 2:30PM, a review of Resident #103's electronic medical record failed to reveal documentation of a care plan for the residents' refusals of showers, any actions taken by the nursing staff to educate the resident, and any alternatives the nursing staff have taken to meet the resident's needs. On 12/12/2024 at 11:40AM, during an interview with Unit Manager #54, the Surveyor confirmed that if a resident was refusing showers, that resident should be care planned for refusal of showers. The Surveyor expressed the concern that documentation had been reviewed in Resident #103's medical record, which indicate they have been refusing showers and there was no care plan nor education developed and implemented for refusal of showers. On 12/12/2024 at 1:00PM, the Surveyor informed Administrator #1 of the concern regarding failure to develop and implement a care plan for a resident refusing showers.

Based on record review and interview with staff, it was determined that the facility failed to facilitate timely care plan meetings after a resident's quarterly assessment to allow the resident and resident representative to participate in the care planning process. This was evident for 1 (Resident #48) out of 2 residents investigated for care planning during the survey. The findings include: Interdisciplinary team (IDT) is a team of medical professionals that provide specific patient centered care to the residents within a facility. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility. On 12/4/2024 at 11:53AM, during an interview with Resident #48, the Surveyor discovered that the resident had a care plan meeting in November 2024, however, it was the first care plan meeting in about 7 months. On 12/5/2024 at 2:00PM, a review of Resident #48's paper medical record revealed a care plan meeting sign in sheet with attendance logs for meetings on 2/14/2024 and 11/14/2024. On 12/6/2024 at 8:47AM, the Surveyor conducted and interview with Social Services Director #13 and the Director of Nursing (DON) #2. The Surveyor was informed that care plan meetings are held quarterly, usually within days of the MDS assessment. The Surveyor expressed a concern that Resident #48 did not have a care plan meeting following their MDS assessment in May 2024 and August 2024. On 12/6/2024 at 10:48AM, Social Services Director #13 provided the Surveyor with documentation that a care plan meeting was held on 5/16/2024. Social Services Director #13 and the administrative staff failed to provide the Surveyor with documentation of a care plan meeting in August 2024 following the MDS assessment on 8/6/2024.

Based on record reviews and interviews, it was determined that the facility failed to provide the necessary Range of Motion (ROM) exercises for a resident in the functional maintenance program. This was evident for 1 (Resident #11) out of the 5 residents reviewed for mobility during the survey. The findings include: A functional maintenance program (FMP) is a set of activities designed to help residents maintain or improve their functional abilities, including range of motion (ROM), after therapy. The program aims to maintain the strength, independence, and functionality gained during therapy and prevent or slow further decline in function. On 12/04/24 at 08:09 AM, during an interview with Resident #11, she/he stated that staff did not provide ROM exercises to his/her wrist and hands. The resident had a history of multiple sclerosis with contractures (permanent restriction to the ROM of a joint). On 12/09/24 at 09:15 AM, the restorative aide (staff # 23) was interviewed. She explained that her job as a restorative aide is to carry out the orders written by the Physical Therapist (PT) or Occupational Therapist (OT). Her work contributes to a resident's functional maintenance program (FMP) after therapy has ended, including exercises to maintain or improve ROM. Staff #23 provided a list of residents who are on an FMP. Resident #11 was listed for ROM to right upper joints 2 times a week for 12 weeks and passive ROM to right upper extremities, wrist, and fingers, PRN (as needed) for 7 AM -3 PM and 3 PM -11 PM. Staff #23 stated that the documentation for the tasks should be found in the electronic medical records. A medical record review was conducted on 12/09/24 at 09:34 AM. Daily documentation on the GNA task under the Restorative/Functional Maintenance area indicated that the resident had a Functional Limitation of Range of Motion. On 12/09/2024 at 09:47 AM, an interview with the Director of PT/OT (Staff #20) revealed that residents not getting ongoing therapy by the PT/OT therapists were placed on the functional maintenance program maintained by nursing. When asked about Resident #11's ROM order written for PRN, Staff #20 stated that it was something that the facility had to clarify. A follow-up interview was conducted on 12/09/24 at 11:43 AM with Staff # 23, who stated that Resident #11 had not had ROM for the past several months because she/he would complain about pain. When asked if this was communicated to anyone, Staff #23 stated that she informed Staff #20 but had not informed the nurse or unit manager. Staff #23 also said she could provide documentation of the times ROM was done. On 12/09/24, at 02:39 PM, Staff #23 provided documentation that the PRN ROM was completed for Resident #11 on 10/11/2024, 11/18/2024, and 12/7/2024. On 12/09/2024 at 2:57 PM, the regional nurse (Staff #3) and Director of Nursing (Staff #2) were interviewed. When asked about the FMP program and the PRN order, they both stated that the program was geared toward residents to help maintain their function, and they had to clarify what constitutes PRN ROM. They both indicated that they were unaware that Resident #11 was not getting ROM due to pain. On 12/12/24 at 08:30 AM, the Administrator was informed of the concern about the lack of communication regarding the resident's ROM not being performed and the clarification and meaning of a PRN ROM order that does not indicate when or under what conditions it should be performed.

Based on record review and interview with resident and facility staff, it was determined that the facility failed to offer and provide showers to a dependent resident twice per week. This was evident for 1 (Resident #103) of 2 residents investigated for Activities of Daily Living (ADL) during the annual survey. The findings include: On 12/4/2024 at 11:40AM, the Surveyor conducted an interview with Resident #103, which revealed that the resident would like to have a shower and that he/she had not had a shower in a long while. On 12/9/2024 at 7:00AM, during an interview with Geriatric Nursing Assistant (GNA) #55, the Surveyor was informed that residents are scheduled to have two showers a week and showers are usually given during the 7AM-3PM shift or 3PM-11PM shift. During review of Resident #103's task care report for November 2024 and December 2024 on 12/9/2024 at 1:30PM, the Surveyor reviewed a GNA task for showers/tub bath on Mondays and Thursdays during the 3pm-11pm shift. Further review revealed that the resident did not receive a shower in November 2024 through December 2024. On 12/10/2024 at 7:26AM, the Surveyor reviewed the facility's Skin: Preventative Care Policy and discovered that residents will receive a shower or tub bath twice weekly and PRN. On 12/10/2024 at 10:25AM, a review of the shower sheet binder at the 1st floor nurses station revealed that Resident #103 followed a Wednesday and Saturday 7am-3pm shower schedule. During further review, the Surveyor did not observe any shower sheets for Resident #103 in the binder. The Surveyor requested Resident #103's shower sheets for November 2024 and December 2024. During an interview conducted with Resident #103 on 12/10/2024 at 10:34AM, the Surveyor asked the resident if he/she had a shower recently and the resident shook his/her head no. The Surveyor asked the resident if he wanted a shower, and he/she said yes. The Surveyor asked if he/she ever refused a shower, and the resident said no. The Surveyor asked the resident if he/she was offered a shower, and the resident said no. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. A review of Resident #103's annual MDS assessment dated [DATE], section F, revealed that it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. Additional review revealed that the resident was dependent on staff for ADL care. On 12/10/2024 at 2:10PM, a review of Resident #103's shower sheets revealed the resident refused a shower on Wednesday 11/6/2024, Wednesday 11/13/2024, Wednesday 11/20/2024, Wednesday 11/27/2024, and Wednesday 12/4/2024. There were no shower sheets for the Saturday shower schedule during November or December 2024. Additional review of the electronic medical record failed to support showers offered or received twice per week. On 12/11/2024 at 10:45AM, the Surveyor conducted an interview with Resident #103. During the interview, the Surveyor discovered that the resident had a shower that morning. The Surveyor was informed that the resident was offered a shower and was happy to receive one. The Surveyor asked the resident if he/she knew what days he/she was scheduled for a shower and the resident stated no. The Surveyor informed the resident that he/she is scheduled to have showers two times a week on Wednesdays and Saturdays. During an interview conducted with Unit Manager #54 on 12/12/2024 at 11:45, the Surveyor confirmed that Resident #103 had not had a shower on Wednesdays and Saturdays as scheduled during the month of November 2024 and December 2024, until 12/11/2024. The Surveyor reviewed the concern that during the survey, Resident #103 stated that it had been a while since he/she was offered showers, he/she has not refused showers, would like to have showers, and was not informed of his/her shower schedule. On 12/12/2024 at 1:00PM, the Surveyor informed Administrator #1 of the concern with Resident #103's showers.

Based on record review and interview with staff, it was determined that the facility failed to ensure a physician's order for a STAT (without delay) x-ray was performed timely, preventing a delay in treatment. This was evident for 1 (Resident #34) out of 3 residents investigated for accidents during the survey. The findings include: On 12/4/2024 at 11:36AM, during an interview with Resident #34, the Surveyor was informed that the resident sustained an injury to his/her left ankle in June 2024 while attempting to be weighed using a wheelchair scale. On 12/6/2024 at 10:00AM, a review of Resident #34's electronic medical record revealed a change in condition note written on 6/14/2024 at stating the resident complained of left ankle pain and the resident stated that he/she got his/her left leg caught on the scale while he/she was being weighed on 6/13/2024. Further review of Resident #34's electronic medical record revealed an physician order for a STAT(without delay) x-ray placed on 6/14/2024 at 1:31PM and confirmed by Registered Nurse (RN) #56. The left x-ray exam was completed on 6/14/2024 at 10:23PM. The findings were reviewed on 6/15/2024 at 7:09AM and confirmed a left ankle fracture. The results were reviewed by the physician and the resident was transferred to the hospital on 6/15/2024 at 1:59PM. During an interview with Regional Nurse #3 on 12/9/2024 at 7:20AM, the Surveyor was informed that STAT orders should be performed within 4-6 hours after the order was placed and called in to the radiology company by the nurse. On 12/9/2024 at 10:07AM, the Surveyor reviewed the provider application for the x-ray for Resident #34 which revealed that the order was called in to the company on 6/14/2024 at 2:09PM by RN #56 and the priority was labeled Routine, a same day request, and was assigned to a technologist at on 6/14/2024 at 2:10PM. During an interview conducted with RN #56 on 12/9/2024 at 2:35PM, the Surveyor reviewed the provider application and the priority stating Routine. RN #56 stated she called in a STAT order for the x-ray and informed the Surveyor that the nurses have to call the company to follow up on orders placed because there is often a delay in services provided. On 12/9/2024 at 2:55PM, Regional Nurse #3 and the Surveyor confirmed the a physician order for a STAT x-ray was called in to the diagnostic company as a Routine x-ray. The Surveyor reviewed the concern for a delay in treatment with Regional Nurse #3.

Based on interviews, and administrative record reviews, it was determined that the facility staff failed to complete annual nursing aide performance reviews. This was evident for 3 out 7 ( GNA #28, GNA #31, and GNA #53) nursing aide performance appraisals, reviewed during the survey. The findings include: On 12/09/2024 at 8:59 AM, the review of employee records for Geriatric Nursing Assistant (GNA) #28 revealed the last performance review was conducted on 8/29/18, and GNA #31 showed no evidence of a performance review. On 12/11/24 at 8:16 AM, the surveyor requested annual performance reviews for GNA #23, GNA #28, GNA #31, GNA #52, and GNA #53. On 12/11/24 at 9:44 AM, the surveyor received employee performance appraisal for GNA #23, and GNA #52. On 12/11/24 at 1:12 PM, the Administrator #1 informed the surveyor that Human Resource personnel were having difficulty locating the performance appraisals for GNA #28, GNA #31, and GNA #53. On 12/12/2024 at 7:08am, during an interview with the Human Resource Director (HR) #47 regarding the process for employee annual reviews, she explained that she tracks all employees' annual performance reviews and completes her portion of the appraisal. One month prior to the review due date, she submits the documentation to the employee's manager with a deadline date. One week before the due date, she follows up verbally with the manager, and if the review is still not received, she follows up via email. When asked about the annual employee appraisals for GNA #28, GNA #31, and GNA #53, the HR Director #47 stated that two of the three performance appraisals were completed on 12/11/24. She explained that the remaining employee works the weekends and plans to complete their review upon their return to work. On 12/12/24 at 9:56AM, during an interview with Unit Manager #26, regarding GNA annual reviews she explained that employees are evaluated, and the HR Director #47 provides notification one month prior to the review due date. She further explained that the HR Director #47 follows up a few days before the deadline. The Unit Manager #26 reported that she is behind on several employee performance reviews due to being assigned multiple job responsibilities.

Based on record review and interview with staff, it was determined that the facility failed to maintain accurate medical records. This was evident for 2 (Resident #51 and #129) out of 61 resident records reviewed during the survey. The findings include: Maryland Medical Orders for Life-Sustaining Treatment (MOLST) is a form which includes medical orders for emergency medical services or other medical personnel regarding CPR (cardiopulmonary resuscitation) and other life-sustaining treatment options. Cardiopulmonary resuscitation (CPR) is a lifesaving technique used in emergencies in which someone's breathing or heartbeat has stopped. 1) On [DATE] at 12:26PM, a review of Resident #51's paper medical record revealed a MOLST form dated [DATE] and elected a full code status to attempt CPR. An additional review of Resident #51's electronic medical record revealed an Advanced Directive Note which indicated the resident was to remain a Full Code and that an updated MOLST form was completed to reflect that on [DATE]. Do Not Resuscitate (DNR) is an order placed in a person's medical record by a doctor informs the medical staff that CPR should not be attempted. 6 Do Not Intubate (DNI) is an order placed in a person's medical record by a doctor informs the medical staff that chest compressions and cardiac drugs may be used, but no breathing tube will be placed. During a review of Resident #51's electronic medical record on [DATE] at 9:45AM, the Surveyor discovered progress notes written by Physician #51 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] which stated the resident is currently DNR/DNI in the unfortunate event of a cardiopulmonary arrest. On [DATE] at 1:00PM, the Surveyor and the Nursing Home Administrator (NHA) #1 reviewed the concern that Resident #51's current MOLST form code status was Full Code and the documentation within Physician #51's progress notes from [DATE] through [DATE] indicated that the resident was DNR/DNI. 43096 2) On [DATE] at 2:32 PM, the surveyor reviewed three residents' medical records for closed records. The review revealed that Resident #129 was found unresponsive in bed on [DATE] at 1:30 AM, and no code was called per Advanced Directive. Further review of progress notes revealed that the licensed practical nurse (LPN #41) wrote, Patient (Resident #129) was presently on hospice; hospice nurse notified of the situation. A review of Resident #129's medical records on [DATE] at 9:06 AM revealed that the resident's hospice care consent was signed on [DATE]. The change in condition form dated [DATE] documented that the resident enrolled in hospice care. However, MDS (Minimum Data Set: a part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated [DATE] was not coded the resident's hospice status. On [DATE] at 9:52 AM, Staff #8 (Regional Nurse) and Staff #42 (MDS coordinator) insisted that Resident #129 did not receive hospice since the court order of care guardian, who signed the resident's hospice care consent, had not been adequately documented: on page 2, option A or option B was not selected, remained blank. Staff #8 said, Since number 2 under option B (the court order) was checked, we believed the order meant option B. However, to avoid making a hasty judgment, we requested and waited for confirmation from the court. That's why even though Resident #129's hospice consent was signed, his/her hospice care was not started till the resident passed away. The surveyor reviewed Resident #129's medical records on [DATE] at 10: 00 AM. The review revealed that the hospice nurses documented notes from [DATE] to [DATE]. Also, progress notes from [DATE] to [DATE] were reported by nurses about being informed/discussed with hospice nurses about Resident #129's condition. In an interview with Staff #8 on [DATE] at 11:11 AM, Staff #8 confirmed that Resident #129 received palliative care under [contracted Hospice care group]. The surveyor asked to provide any documentation to support the resident receiving palliative care, not hospice care. Staff #8 stated that the facility did not have it. On [DATE] at 3:03 PM, the surveyor informed the above concern in an interview with the Director of Nursing (DON). The DON validated it.

Based on medical record reviews, staff interviews, it was determined that the facility failed to develop a comprehensive care plan. This was evident for 1 of 9 residents ' (Resident #1) records reviewed during a Focused Infection Control and complaint survey (MD 026). The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of a resident ' s medical care and treatment(s). On 01/05/22 at 11:30 AM a review of Resident #1 ' s medical record revealed the resident was admitted to the facility on [DATE] from an acute care facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . According to hopkinsmedicine.org, a halo-vest is a brace that is used to immobilize and protect the cervical spine and neck after surgery or accident. The halo is a ring that surrounds the head and is attached by pins to the outer portion of the skull; however, some Halos are pinless but are only used in certain situations https://www.hopkinsmedicine.org/[NAME]-hopkins-childrens-center/what-we-treat/specialties/orthopaedics/_documents/form_halo-vest.pdf. On 1/5/22 at 11:45 AM a review of Resident #1 ' s order for skin care revealed on 1/1/20 a physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident ' s care plan revealed the facility ' s staff failed to develop a care plan which included nursing treatment or intervention for Resident #1 ' s Halo and skin according to the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] On 01/05/22 at 2:00 PM in an interview with the Director of Nursing (DON) the existing skin care plan for the resident was reviewed. The DON verified nursing staff failed to develop a care plan which included nursing care treatment and interventions for Halo and affected skin as ordered involving Resident #1. All concern was discussed with Nursing Home Administrator and Director prior and during survey exit on 01/06/22 at 3:15 PM. No additional information was provided prior to exit.

Based on medical record review and interview, it was determined the facility staff failed to maintain medical records in the most accurate form for a resident. This was evident for 1 of 5 residents (Resident #5) reviewed during a complaint survey. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Review of Resident #5's medical record on 3/4/20 revealed the Resident was admitted from the hospital on [DATE] for rehabilitation and medical management. Review of the Resident's hospital discharge summary dated 1/25/20 revealed the Resident had [DIAGNOSES REDACTED]. The hospital discharge summary physical exam included the Resident's power to his/her left upper and lower extremities was a 3 out of 5 and 1 out of 5 for the Resident's right upper and lower extremities. Further review of Resident #5's medical record revealed the facility staff completed a Nursing Admission Database assessment on 1/25/20 at 8:55 PM. The facility staff documented No to history of [MEDICAL CONDITION]. The facility staff documented motor control was within normal limits. The facility staff documented upper and lower extremities strength was within normal limits. Further review of the Nursing Admission Database the facility staff failed to [MEDICAL CONDITION] list of [DIAGNOSES REDACTED]. An anticonvulsant is a medication used in the treatment of [REDACTED]. Interview with the Director of Nursing and Regional Nurse on 3/5/20 at 1:00 PM confirmed the surveyor's findings.

Based on medical record review and interview it was determined that the facility failed to ensure the development of a baseline care plan that included instructions needed to provide effective and person centered care within 48 hours of admission. This was evident for 1 out of 5 residents (Resident #5) reviewed during the complaint survey. The findings include: Review of Resident #5's medical record on 3/4/20 revealed the Resident was admitted to the facility on [DATE] from the hospital for rehabilitation. On admission the Resident was ordered Physical Therapy (PT) to evaluate and treat as needed. Further review of the resident's medical record revealed [REDACTED].#1 on 1/27/20. Continued review of the PT's daily treatment note for Resident #5 on 1/27/20 revealed Physical Therapist #1 documented the Resident demonstrates increased [DIAGNOSES REDACTED] both lower extremities limiting functional balance and endurance. Patient requires max assist with postural balance, weight shift and maintain functional sitting balance. Review of the Resident #5's care plans on 3/4/20 revealed a care plan for 1.) Risk for/Actual activity intolerance with no goals or interventions and 2.) Safety risk with no interventions. Further review of Resident #5's care plans revealed 3 additional care plans for pain, imbalanced nutrition and risk for impaired skin integrity. Further review of the resident's medical record revealed [REDACTED]. The Physical Therapist #1 daily treatment note for Resident #5 on 1/27/20 was reviewed by the surveyor with the Director of Rehabilitation (DOR) on 3/4/20 at 11:50 AM. The DOR was asked based on the Physical Therapist #1 documentation what would Resident #5 need when out of bed. At that time the DOR stated the Resident would need to be placed in a reclined high back wheelchair. During interview with Physical Therapist #1 on 3/4/20 at 2:14 PM, she stated she evaluated Resident #5 on 1/27/20 in bed. She stated her evaluation included positioning and she deemed the Resident would be safe in a reclined high back wheelchair. Physical Therapist #1 was asked how would the staff know that was what the Resident needed and she stated the staff usually comes to the department and ask. During interview with the 1st floor Unit Manager on 3/4/20 at 2:20 PM, the Unit Manager was asked how the facility staff know what a resident needs after a therapy evaluation. She stated the therapy staff enter orders and notes in the electronic medical record. Further review of Resident #5's medical record revealed no orders, therapy notes or baseline care plan to indicate the Resident needed to be in a reclined high back wheelchair. Interview with the Director of Nursing and Regional Nurse on 3/5/20 at 1:00 PM confirmed the surveyor's findings.

Based on medical record review and interview, it was determined the facility staff failed to ensure that medication regimens were free from unnecessary medications for residents. This is evident for 2 out of 5 residents (Residents #2 and #3) reviewed during a complaint survey. The findings include: 1. Review of Resident #2's medical record on 3/3/20 and 3/4/20 revealed the Resident was readmitted to the facility on [DATE]. Further review of Resident #2's medical record revealed that on 9/29/19 the physician ordered [MEDICATION NAME] 100 mg three times a day for hypertension, hold for systolic blood pressure less than 130. [MEDICATION NAME] is a medication used to treat high blood pressure. Review of the Resident's Medication Administration Record [REDACTED] 11/1/19 at 10:00 PM with a blood pressure of 121/67 12/9/19 at 2:00 PM with a blood pressure of 123/81 12/11/19 at 2:00 PM with a blood pressure of 120/70 12/21/19 at 2:00 PM with a blood pressure of 120/66 12/22/19 at 2:00 PM with a blood pressure of 118/70 12/24/19 at 10:00 PM with a blood pressure of 128/76 12/26/19 at 6:00 AM with a blood pressure of 123/60 12/30/19 at 2:00 PM with a blood pressure of 122/70 1/1/20 at 6:00 AM with a blood pressure of 120/60 1/4/20 at 2:00 PM with a blood pressure of 128/60 1/6/20 at 6:00 AM with a blood pressure of 128/68 Further review of Resident #2's medical record revealed on 9/29/19 the physician ordered: [MEDICATION NAME]3 units every 6 hours related to diabetes. Hold if blood sugar less than 120. Review of the Resident's MAR for November 2019, December 2019 and January 2020 revealed the Resident received [MEDICATION NAME]when the Resident's blood sugar did not meet the parameters for administration on: 11/14/19 at 6:00 PM with a blood sugar of 115 12/4/19 at 12:00 AM with a blood sugar of 101 2. Review of Resident #3's medical record on 3/3/20 and 3/4/20 revealed the Resident was admitted to the facility on [DATE] from the hospital. Further review of the Resident's physician's orders [REDACTED]. Review of the Resident's MAR indicated [REDACTED]. During interview with Resident #3's responsible party on 3/4/20 at 11:02 AM, he/she stated when visiting the Resident on the evening of 1/31/20, he/she observed 3 patches on the Resident with no date or time. The responsibility party stated he/she notified the staff at the time. During interview with the Nurse Supervisor on 3/4/20 at 12:00 PM, she stated she observed Resident #3 with 3 [MEDICATION NAME]es with no date or time on them. The Nurse Supervisor stated she removed 2 of the patches and advised the Director of Nursing of the incident. Interview with the Director of Nursing and Regional Nurse on 3/5/20 at 1:00 PM confirmed the facility staff failed to administer medications as ordered by the physician.

Based on a review of the facility investigations, medical records, interviews with facility staff and other pertinent documentation it was determined that the facility failed to 1) document a Rehabilitation screen was done for resident #89, 2) document the correct dates on a narcotic sheet for Resident #123) and 3.) accurately document on the controlled drug receipt record for a resident that received a narcotic medication (#173). This was true for 3 of 39 residents reviewed during the annual survey. The findings include: 1. Review of Resident #89's medical record on 12/16/19 at revealed on 6/15/19 the resident was noted with a bruise to the right upper inner arm. According to the facility investigation, it was determined that the bruise to the right upper inner arm was consistent with the leaning position of the resident in the wheelchair. The investigation noted the resident was referred to Rehab for positioning and seating. Continued review of the medical record failed to reveal a rehab screen and/or documentation that the resident was evaluated by rehab for seating and positioning. During an interview with the Director of Rehab on 12/16/19 at 1:00 PM, she reported the screen was done and there were no recommended changes, however, staff forgot to document and place the rehab screen on the chart. 2. Review of Resident #123's medical record on 12/17/19 at 11:00 AM revealed a physician order [REDACTED]. Further review of the medical record revealed the following: [NAME] On 3/25/19 at 1:23 PM the resident was medicated with [MEDICATION NAME] tablet 5mg for pain by registered nurse (RN) #5, however, the narcotic count sheet was dated 2/25/19 at 1:15 PM. B. On 3/26/19 at 12:54 AM the resident was medicated with [MEDICATION NAME] tablet 5mg for pain by licensed practical nurse (LPN) #3, however, the narcotic count sheet was dated 2/26/19 at 12:54 AM. C. On 3/26/19 at 11:00 AM the resident was medicated with [MEDICATION NAME] tablet 5mg for pain by LPN #4, however, the narcotic count sheet was dated 2/26/19 at 11:00 AM. During an interview with the Director of Nursing, the Regional Nurse and the Administrator on 12/17/19 at 2:00 PM, it was verified that RN #5, LPN #3 and LPN #4 documented the incorrect date on Resident #123's narcotic count sheet. 3. During the investigation of complaint MD 782 and review of the medical record revealed for Resident #173 on 12/17/19 at noon revealed a physician order [REDACTED]. [MEDICATION NAME] CR is a medication used to help relieve severe ongoing pain. Continued review of the medical record revealed a Controlled Drug Receipt/Record Disposition Form dated 7/12/19 for Resident #173 which revealed on 7/13/19 at 3:40 AM the medication was signed as being administered, however, a line was drawn through the time and written above the line was 6 AM. Further review of the medical record revealed the resident refused the medication at 3:40 AM, however, refusal was not documented on the Controlled Drug Receipt/Record Disposition Form. An interview was conducted with the DON on 12/17/19 at 12:30 PM and she was asked why the drug receipt log had a line drawn through the time of 3:40 AM with another time of 6 AM written above it. The DON stated that the nurse should have another nurse witness and sign if the medication was destroyed and not given. In a later interview on the same date, Regional Nurse # 3 returned to the survey team and explained that the facility was conducting an audit and education was being provided to staff presently.