Every finding on record at Moran Nursing and Rehabilitation Center

Based on record reviews and interviews, it was determined that the facility failed to provide adequate supervision to a resident to prevent an elopement. This was evident for 1 (Resident #103) of 3 residents reviewed during the complaint survey.The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facility's plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 7/3/26The findings include:Resident #103 Was admitted into the facility in early 2025 with diagnosis that included dementia. A facility reported incident (FRI) with intake #3067346, indicated that the resident was found outside on 7/1/26 at 7:50 PM, wandering the facility parking lot. The resident was escorted back into the facility by the Director of Nursing (DON).A review of Resident #103's medical record was conducted on 8/10/26 at 11:23 AM. The review revealed an Assessment with the reference date of 7/24/26 where section C indicated that the resident was cognitively impaired and section E indicated that the resident had wandering behaviors. Further review of the resident's medical record revealed that the resident was an elopement risk since 1/20/25 and that a wanderguard was in place.WanderGuard is an electronic wander management system used in senior living and memory care facilities to protect residents with cognitive impairments, like Alzheimer's or dementia, from leaving unsupervised. It uses wearable transmitters like bracelets or pendants that trigger door locks, alarms, or staff alerts when a wearer nears an exit.A review of the facility's investigation packet for the FRI was conducted on 8/10/26 at 11:30 AM. The review indicated that a staff member went into the unit where Resident #103 was residing, using the elevator. Before the elevator doors closed, the resident slipped into and had accessed the elevator unsupervised, got off the lobby and walked out of an unattended front door. The review also indicated that the wanderguard did not trigger the alarm when the resident walked out but did so when the DON was escorting the resident back into the facility.A review of the facility's action plan with credible evidence was conducted on 8/10/26 at 12:18 PM. The review revealed the following:a)Resident #103's wanderguard bracelet was replaced with a new one on 7/1/26b)All other wanderguards on other residents were checked and verified to be functioningc)Elopement assessments were conducted for all residents of the facility and were completed on 7/2/26d)All staff members were educated on elopement plan that included checking wanderguard functionality with approved device, escorting visitors out of the facility when the receptionist leaves, not sharing elevator keypad code, and not walking away from elevator doors before they close. Education was completed on 7/2/26 and verified on 7/3/26e)Elevator code was changed on 7/3/26f)Maintenance staff changed inspection of wanderguard system and doors from weekly to daily.g)Quality assurance meeting was conducted on 7/2/26On 8/10/26 at 12:44 PM, the Nursing Home Administrator (NHA) was interviewed regarding the FRI. She confirmed the details and the facility's action plan above and reported that when the alarm is triggered by the wanderguard, it cannot be reset remotely and a staff member would need to physically put the code in by the front door and during the time of the incident with Resident #103, the alarm was only triggered when the resident was escorted back into the building. She also reported that one of the biggest changes was escorting visitor when they leave the facility after the receptionist leaves for the day at 6 PM.The Maintenance Director (Staff #1) was interviewed on 8/10/26 at 2:28 PM. During the interview, he explained his process in checking the wanderguatrd system. He also provided documentation of his weekly check prior to the incident and had not identified any concern with the functionality and stated, there's nothing we can do to make that thing fail.A subsequent review of Resident #103's medical record on 8/11/26 at 10:40 AM revealed that the order to check the placement and functionality of the wanderguard was initiated on 1/20/25 and no concern was identified with its documentation.During an interview with the NHA along with the DON on 8/11/26 at 1:40 PM, the concern was discussed that the facility failed to provide adequate supervision to Resident #103, as evidenced by the resident leaving the facility without anyone's knowledge or supervision. However, based on the above actions taken by the facility and verified by the surveyor on site, it was determined that the facility's deficient practice was past-noncompliance with a compliance date of 7/3/26. Both staff verbalized understanding and acknowledged the concern.

Based on interviews, record reviews, and observations, it was determined that the facility failed to follow guidance from the Maryland Department of Health (MDH) and the facility's corrective action plan to prevent the risk of exposure to Legionella and failed to ensure infection control practices were implemented to minimize the potential spread of pathogens, including maintaining a designated handwashing sink, appropriate use of personal protective equipment (PPE), and proper cleaning of equipment. This was evident for 1 of 1 Legionella corrective action plans reviewed and 3 of 3 infection control practices observed while performing the infection control task during the annual survey.The findings include:1.) There is significant risk for Legionella bacteria growth when shower lines in a long-term care facility are left stagnant or unused. Stagnant water promotes biofilm formation, creating an ideal environment for Legionella multiplication. Aerosolized contaminated water can expose residents during shower use, placing elderly and immunocompromised residents at increased risk for Legionnaires' disease, a severe form of pneumonia. On 5/11/26 at 1:10 PM, during the initial screening process, Resident #4 reported ongoing water issues. Observation of the resident's private bathroom revealed multiple personal items piled in the shower, preventing use. Resident #4 stated they had been told the shower could not be used due to water issues and were required to shower in the community shower down the hall. On 5/11/26 at 1:59 PM, the surveyor interviewed the Maintenance Director (Staff #14), who acknowledged ongoing water issues due to the age of the building. When asked why Resident #4's shower was inaccessible, he stated residents were not permitted to use private showers and were required to use community showers. On 5/13/26 at 10:38 AM, GNA #18 confirmed there had been ongoing water issues related to possible Legionella and stated resident room showers were not to be used, although some remained operational. On 5/13/26 at 11:40 AM, the surveyor again interviewed the Maintenance Director (Staff #14), who confirmed he was aware residents had been instructed not to use room showers but stated he was unsure why. When asked about Legionella concerns, he acknowledged there had been issues in the past. He stated showers were not tested because they were not used and that most of the water access to the showers has been turned off. On 5/13/26 at 11:52 AM, the Maintenance Director (Staff #14) stated showers were not routinely flushed and were only flushed if drains produced an odor. He further stated, housekeeping flushes the sinks on occasion and initially reported there was no official log documenting the flushing. On 5/13/26 at 12:00 PM, the surveyor reviewed Legionella documentation provided by the Maintenance Director and identified a document titled 3/2/26 Summary of Legionella Testing and Prevention Activities since 12/29/25. The document reflected positive hot water Legionella test results on 1/7/26 and again on 1/29/26 in two separate resident rooms. The local health department was notified and, because no residents tested positive, directed the facility to complete remediation activities as recommended by the water treatment specialist (NALCO), including flushing affected lines, replacing fixtures as needed, retesting, and ongoing daily flushing of room water lines by staff as part of continued prevention efforts. On 5/13/26 at 12:10 PM, the surveyor interviewed the Environmental Services Director (Staff #15), who stated he was newly hired and unaware of a checklist or process requiring daily flushing. During this interview, Housekeeper (Staff #16) stated staff were expected to flush sinks daily but confirmed resident room showers were not flushed and only public showers were run. Staff #16 stated logs were completed and returned monthly to Maintenance. On 5/13/26 at 12:17 PM, the surveyor again questioned the Maintenance Director regarding flushing logs. He then produced logs after previously stating none existed and replied, I wasn't trying to hide anything, I must have misunderstood what you were asking for. He further confirmed there was no log identifying which resident room showers were operational versus shut off. On 5/13/26 at 12:24 PM, the surveyor interviewed the Nursing Home Administrator (NHA) and Director of Nursing (DON) regarding resident room showers. Both stated showers were not used for safety purposes due to fall risk. The NHA confirmed two sinks had previously tested positive for Legionella and stated all resident showers except room [ROOM NUMBER] had been shut off. On 5/13/26 at approximately 12:38 PM, two surveyors tested showers in Rooms 308, 307, 322, 316, and 317. All showers were operational except room [ROOM NUMBER], contradicting the facility's statement that resident room showers had been shut off. On 5/13/26 at approximately 1:30 PM, the surveyor reviewed additional Legionella documentation and identified a 1/8/26 email from the local health department to the Infection Preventionist (ICP #3), directing the facility to implement enhanced surveillance, including evaluating residents with respiratory symptoms for pneumonia, ordering chest x-rays, immediately reporting new pneumonia cases, performing Legionella diagnostic testing, maintaining line lists of respiratory illness, designating a staff member to conduct surveillance, and maintaining surveillance for six months following the last facility-associated case. On 5/13/26 at 3:09 PM, the surveyor interviewed ICP #3, who acknowledged awareness of prior positive Legionella findings within a sink but stated residents were only tested for Legionella after a confirmed pneumonia diagnosis and not when presenting with respiratory symptoms. Review of respiratory illness line listings revealed 16 residents experienced respiratory-related symptoms in March 2026, including shortness of breath, wheezing, runny nose, chills, and rhonchi. Of those residents, three were diagnosed with pneumonia, two with bronchitis, and two tested positive for Human Metapneumovirus (HMPV). ICP #3 confirmed only residents diagnosed with pneumonia were tested for Legionella, confirming the facility failed to implement enhanced Legionella surveillance as directed by the local health department for residents presenting with respiratory symptoms. On 5/13/26 at approximately 3:30 PM, the surveyor reviewed sink flushing logs and noted incomplete documentation. Logs lacked dates, room numbers, staff identifiers, and did not reflect daily flushing as required by the facility's written remediation plan. Shower flushing was not included. On 5/13/26 at 3:40 PM, the surveyor interviewed the Regional Clinical Director (RCD #11) and NHA regarding concerns related to unmonitored showers, incomplete flushing documentation, and failure to follow local health department guidance for resident surveillance. Both acknowledged these concerns. On 5/13/26 at 4:15 PM, the surveyor reviewed the local health department guidance email with ICP #3, who stated she had misunderstood the guidance and confirmed residents with respiratory symptoms had not been tested as directed. On 5/13/26 at 4:22 PM, the surveyor interviewed the RCD (#11), NHA, DON, and Maintenance Director (#14). The Maintenance Director confirmed there was no log identifying which showers were operational, resident room showers were not flushed daily, sink flushing was inconsistently performed and poorly documented, and stagnant shower lines created Legionella risk. All present agreed these practices were not consistent with the facility's documented Legionella prevention plan dated 3/2/26. On 5/14/26 at 11:55 AM, the surveyor interviewed facility administration regarding Quality Assurance Performance Improvement (QAPI) oversight of the Legionella issue. The facility later confirmed the Legionella issue had not been incorporated into QAPI for monitoring and follow-up. Cross Reference F867 2.) On 05/12/2026 at 11:45 AM, the surveyor noted that a commercial-grade handwashing sink was not available in either of the two soiled laundry rooms. One soiled laundry room was used for sorting laundry into four different bins, while the second room was used for loading soiled laundry into the washing machines. Only one utility sink was located in the corner of the laundry machine room directly below the wall-mounted paper towel and soap dispensers. An interview with the Healthcare Services Group Environmental Services (EVS) Director confirmed that the utility sink was being used as an eye washing station, soiled laundry soaking station, and a handwashing sink. At 2:40 PM, a follow-up tour of the laundry rooms was conducted with the Maintenance Director. During the interview, the Maintenance Director confirmed that there were no designated handwashing sinks in either of the soiled laundry rooms to support proper hand washing practices. At 3:30 PM, a tour of the third-floor soiled utility room was conducted with the Maintenance Director. During the tour, the surveyor noted that the hopper was visibly damaged and labeled with an OUT OF ORDER sign. An interview with the Maintenance Director confirmed that the specialized clinical sink would be replaced as soon as possible to clean and sanitize bedpans, urinals, and basins for proper disposal of liquid and semi-solid waste and bodily fluids. On 5/14/2026 at 10:30 AM, a second follow-up tour of the laundry rooms was conducted with the Infection Preventionist (IP) and the EVS Director. During the tour, the surveyor addressed that the two separate soiled laundry rooms lacked designated handwashing sinks and the laundry machine room lacked appropriate PPE, including gowns, gloves, and eye googles for staff handling soiled laundry. The IP acknowledged that designated handwashing sinks were required and stated that PPE would be provided in both soiled laundry rooms as soon as possible. Furthermore, the nonfunctional hopper on the third-floor soiled utility room would be replaced to minimize the risk of possible cross-contamination.

Based on observation, and interview with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the kitchen tour of the annual survey. The findings include:A food-contact surface refers to any surface of equipment and utensils that typically comes into contact with food; or from which food may drain, drip, or splash onto food; or a surface that is usually in contact with food. On 05/12/2026 at 9:25 AM, the surveyor conducted a tour of the kitchen alongside the Certified Dietary Manager (CDM) and identified the following deficient practices:Multiple cove base tiles were missing throughout the kitchen areas creating gaps and holes along the walls that could harbor pests and bacteria.Food carts, hot plate warmers, and dish tray rolling racks were unclean and heavily soiled with dust, dirt, debris, and accumulated food spills. The drywall underneath the dish machine, measuring about 24 inches by 36 inches, was in disrepair with significant chipping and peeling paint along with accumulation of dirt, dust, and food spills.Steam, vapor, and heat were observed escaping from the high-temperature conveyor dish machine. In addition, the surrounding walls and caulked edges showed significant buildup of mold-like substances. The kitchen environment was warm and humid with stagnant air, indicating insufficient airflow from the canopy hood ventilation system, and the local exhaust system in the designated wash-down area located at the corner of the kitchen.The wall-mounted fans were unclean and had excessive buildup of dust, dirt, and debris. The stainless-steel floor panels and the thresh board plates in the walk-in coolers were lifted, buckled, and warped, creating gaps for buildup of dust, dirt, and food spills.At 2:05 PM, a follow-up tour of the kitchen was conducted with the Maintenance Director and CDM to go over the findings listed above.

Based on observations, interviews, and record review, it was determined that the facility failed to treat residents with respect and dignity, as evidenced by failing to knock and request permission before entering a resident's room. This was evident for one (Resident #31) of one Resident reviewed for dignity. The findings include:On 5/13/26 at 6:57 AM, an observation showed that Resident #31 had activated the call light for help. Staff #13, a nursing assistant, entered Resident #31's room in response to the call light, and the surveyor was also present in the resident's room. The observation failed to show that Staff #13 knocked on the resident's door, announced herself, or requested permission before entering the resident's room.During an interview at that time, Staff #13 was asked whether she knocked on Resident #31's door before entering the room. Staff #13 indicated that Resident #31's door was already open, so she did not knock. Staff #13 then added that she should have announced herself, even though the resident could not answer her anyway.A record review later that day included progress notes indicating that Resident #31 was alert and oriented but had difficulty communicating due to a history of aphasia. However, Resident #31 communicated his/her needs using a communication board and signs/gestures, made himself/herself understood, and was usually understood by others.In an interview on 5/14/26 at 11:08 AM, the assistant director of nursing (ADON) reported that staff #13 had already informed her that the surveyor had expressed concern about not knocking on Resident #31's door before entering. The ADON added that she expected that staff would knock and announce themselves before entering any resident's room.

Based on record review and interviews, it was determined that the facility failed to ensure the attending provider documented in the resident's medical record that they reviewed a pharmacist's recommendations and the attending provider's rationale for declining. This was evident for 2 (Resident #5 and Resident #31) of 5 Residents reviewed for unnecessary medications. The findings include: 1)A review of Resident #5's medical record on 5/13/26 at 11:14 AM revealed a pharmacy medication regimen review (MRR) completed on 11/28/25, which recommended discontinuing an antiulcer medication and an omega-3 fish oil medication. Further review of the MRR showed a Physician/Director of Nursing response stating Decline. Further review found that Resident #5's attending physician visited the resident on 12/7/25. In his notes, there was a notation, monthly orders and treatment plan reviewed and signed. The review also noted that Resident #5 had another visit with an attending provider on 12/15/25. However, neither provider's note showed that they reviewed Resident #5's MRR, completed on 11/28/25, with recommendations, nor did it document a rationale for declining those recommendations. During an interview on 5/13/26 at 12:37 PM, the director of nursing (DON) stated that she received the MRR reports with recommendations via email and typically reviewed them with the attending providers by phone. Afterward, she documented the attending provider's response to the recommendations in the report and signed it herself. The DON reviewed Resident #5's electronic medical record and reported that it lacked supporting documentation showing that the provider reviewed the MRR and the rationale for declining the recommendations. 2) Resident #31 had diagnoses that included, but were not limited to, dementia and anxiety disorder. On 5/12/26 at 1:25 PM, a review of Resident #31's medical record revealed active medication orders, including: Buspirone HCl 7.5 mg, Depakote 125 mg, Rexulti 0.5 mg, and Trazodone 100 mg. Additional documentation from the prescribing psychiatric provider indicated the resident remained compliant with the medication regimen; however, the medical record lacked a documented clinical rationale supporting continuation of the psychotropic medication regimen without GDR. On 5/12/26 at 1:30 PM, a review of pharmacy consultant documentation and the resident's medical record revealed a pharmacist recommendation dated 12/31/25 requesting provider documentation regarding gradual dose reduction for Buspirone HCl 7.5 mg, Depakote 125 mg, Rexulti 0.5 mg, and Trazodone 100 mg. The record contained a provider declination stating no changes at this time; however, the record lacked a documented clinical rationale supporting why a GDR was clinically contraindicated or otherwise not attempted. On 5/13/26 at 12:46 PM, during an interview, the Director of Nursing (DON) reviewed with the surveyor the location of psychiatric nurse practitioner documentation and explained the facility's expectation that documentation include clinical rationale supporting why a gradual dose reduction would or would not be indicated for psychotropic medications. There was no evidence that the provider had assessed and documented that rationale. Further review of psychiatric provider documentation dated 1/6/26, 3/12/26, and 5/11/26 failed to reveal a documented rationale regarding the continuation of the resident's psychotropic medication regimen without gradual dose reduction. On 5/13/26 at 1:00 PM, the DON acknowledged concerns regarding the lack of a documented rationale from the prescribing provider related to the gradual dose reduction for the resident's psychotropic medications.

Based on interviews, observations, and record review, it was determined that the facility failed to ensure that skin assessments were completed accurately, failed to identify and document significant bruising, failed to implement care plan interventions for skin monitoring, and failed to report injuries to facility administration. This was evident for 1 (Resident #53) of 4 residents investigated for potential abuse (Intake #3013659). The findings include:On 5/11/26 at 10:55 AM, during the initial screening process, the surveyor interviewed Resident #53. The resident was observed to have a bruise on the left elbow. When asked about the injury, Resident #53 stated, staff is rushed and often hurt [them] when [they are] moved. The resident added that there is a toxic level of carelessness in the facility.Resident #53's private duty assistant, Geriatric Nursing Assistant (GNA #22), was present in the room and provided the surveyor with a photograph of the resident's elbow showing significant ecchymosis (black and blue bruising). GNA #22 stated the photograph was taken on 4/17/26 following an incident where the resident was injured while a nurse and another GNA were providing care. GNA #22 confirmed that Resident #53 is frequently bruised during bathing and repositioning.On 5/13/26 at 9:51 AM, the surveyor reviewed Resident #53's weekly skin assessments from April 1st through April 30th. The review revealed zero documentation of bruising. All weekly assessments documented the resident's skin as warm, dry, normal color, with no petechiae, normal skin turgor, and no skin alterations.On 5/13/26 at 5:03 PM, the surveyor interviewed the Nursing Home Administrator (NHA), Director of Nursing (DON), and the Regional Clinical Director (RCD #11). The surveyor inquired if administration was aware of an incident where staff injured the resident's elbow. All administrative staff denied knowledge of the incident.On 5/14/26 at 12:20 PM, the surveyor conducted a second interview with Resident #53. When asked if the elbow injury was reported to anyone, the resident stated that Nurse #23 was aware and that the injury occurred during a shower transfer. Resident #53 stated that Nurse #23 assessed the elbow for bruising immediately after the incident, but the bruising took several hours to develop.During this interview, the surveyor observed a residual bruise on Resident #53's left elbow, as well as a new, localized red area. GNA #22 stated that when skin issues are reported, facility staff dismiss the concerns by stating the resident bruises easily.Resident #53 noted that a care plan meeting was scheduled for 2:00 PM that day, and the resident planned to address the recurring bruising caused by careless handling during care.On 5/14/26 at 3:02 PM, the surveyor reviewed Resident #53's care plan, which directed staff to:-Inspect skin, especially over bony prominences, during bathing and personal care (CNA).-Complete weekly wound observations (Licensed nurse).-Use draw sheets or similar assistive devices for positioning and turning to maintain skin integrity.-Apply a protective foam dressing to the left elbow and change as needed.-Educate the resident and caregivers on causative factors and measures to prevent skin injury.-Monitor, document, and report as needed (PRN) any changes in skin status, including appearance, color, and wound healing.-Perform skin inspections every shift and report abnormal findings.-Use caution during transfers and bed mobility to prevent striking limbs against sharp or hard surfaces.On 5/14/26 at 3:30 PM, the surveyor reviewed the GNA daily skin assessments for Resident #53. The review revealed that staff failed to document the bruise to the resident's left elbow on any daily assessment.On 5/14/26 at 3:48 PM, the surveyor interviewed the NHA and DON regarding the lack of skin assessment documentation. The DON confirmed there was no documentation to support that staff identified or recorded Resident #53's bruising on either daily or weekly skin assessments. The DON verified that the elbow injury should have been captured in the resident's medical record.

Based on observations, interviews, and record review, it was determined that the facility failed to ensure that residents who required assistance with Activities of Daily Living (ADLs) received showers. This was evident in one (Resident #20) of three residents reviewed for ADLs. The findings include:The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to collect information on each Resident's strengths and needs. This information informs Resident care planning decisions.On 5/11/26 at 11:55 AM, Resident #20 was observed sitting in a chair by the bedside. The Resident's room had a strong urine-like odor. An interview with Resident #20 at that time indicated that he/she received only one shower per week. A medical record review on 5/12/26 at 12:14 PM included an MDS assessment dated [DATE] for Resident #20. The MDS indicated that Resident #20 required staff assistance with showering. A further review of the shower schedule for the unit where Resident #20 resided showed that Resident #20 was scheduled for 2 showers per week, totaling 8 showers per month. Further review of the nursing assistant's shower documentation for Resident #20 from March 1 to May 12, 2026, was completed. The review revealed that the Resident received 4 showers in March instead of 8, 7 showers in April instead of 9, and 1 shower as of 5/12/26 instead of 3.In an interview on 5/12/26 at 12:42 PM, staff #20, a nursing assistant, reported that nursing assistants were expected to document and report to the nurses whenever a resident refused a shower. Therefore, if Resident #20 refused any showers, it would have been documented. In an interview on 5/12/26 at 1:22 PM, the unit manager (UM) for the third-floor unit stated that she expected every Resident to receive 2 showers per week, and that if any Resident refused, staff were to document the refusal. The interview lacked documentation confirming whether Resident #20 received all his/her scheduled showers or refused any.

Based on record review and staff interview, the facility failed to ensure a resident receiving a as needed (PRN) compounded psychotropic medication had adequate clinical documentation to support administration, including evidence of non-pharmacological interventions prior to use, monitoring for effectiveness and adverse effects, and complete medication order information, for 1(Resident #31) of 1 residents reviewed for unnecessary medications. The findings include:Resident #31 had diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, paranoid schizophrenia, major depressive disorder, aphasia, psychomotor deficit following cerebral infarction, and history of falls.On 5/14/26 at 2:30 PM, a record review revealed Resident #31 had a physician order for a compounded topical medication containing Ativan (lorazepam), Benadryl (diphenhydramine), and Haldol (haloperidol), to be applied topically to the palm side of the wrist twice daily as needed for increased agitation. The physician order did not include documented dosages of the compounded medications, non-pharmacological interventions to attempt prior to administration, or monitoring parameters for effectiveness or adverse effects.On 5/14/26 at 3:15 PM, a review of Resident #31's care plan revealed interventions related to mood and behavior needs, most recently updated 2/8/26, including periods of socially inappropriate behavior, verbal aggression, taking items belonging to others, and refusal of care related to diagnoses including schizophrenia, anxiety, major depressive disorder, anoxic brain damage, and vascular dementia.A review of the electronic Medication Administration Record (eMAR) and nursing progress notes for Resident #31 from 2/1/26 through 5/15/2026 revealed the following:On 2/26/26 at 2:39 AM and 7:31 PM, the compounded psychotropic medication was administered without documented nursing notes indicating non-pharmacological interventions attempted prior to administration or documentation assessing effectiveness following administration.On 3/1/26 at 5:25 AM, the compounded psychotropic medication was administered without a documented nursing assessment, non-pharmacological interventions attempted prior to administration, or follow-up documentation regarding effectiveness.On 3/5/26 at 11:46 PM, the compounded psychotropic medication was administered without a documented nursing assessment, non-pharmacological interventions attempted prior to administration, or follow-up documentation regarding effectiveness.On 5/13/26 at 6:14 PM and again at 6:15 PM, the eMAR reflected administration of the compounded psychotropic medication. Follow-up documentation was entered at 8:28 PM and 8:42 PM. There were no nursing progress notes documenting the resident assessment, prompting administration, non-pharmacological interventions attempted prior to use, clarification regarding whether a discrepancy in administration times occurred, or assessment of medication effectiveness.On 5/15/26 at 11:00 AM, during an interview with the Nursing Home Administrator and Director of Nursing, they acknowledged concerns regarding the lack of documentation related to the administration and monitoring of the compounded psychotropic medication.

Based on review of the medical record, facility investigation documentation and interviews it was determined that the facility failed to keep a resident free from abuse. This was found to be evident for one (Resident #21) of four residents reviewed for abuse during the survey.The findings include:Review of the medical record revealed Resident #21 is a long-term care resident who is cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident has severely impaired vision and requires assistance for transfers and toileting.Review of the Facility Reported Incident (FRI) #2967650 Initial Report Form, submitted on 3/29/26 at 11:50 PM, revealed an allegation that Nurse #6 heard a verbal exchange between Resident #21 and nursing assistant (NA) #9 while the NA was toileting Resident #21. During this exchange NA #9 was shouting at Resident #21 and using foul language. NA #9 loudly shut Resident #21's bathroom door after Resident #21 asked her not to close the door. Review of the facility investigation documentation revealed a signed statements from Nurse #6. Review of Nurse #6's statement revealed that Resident #21 had turned on the call light and was yelling out for help. Prior to going into the room NA #9 yelled out loudly that they had 30 other residents to care for and [s/he] did not have to yell. NA #9 then went into the resident's room and loud yelling was heard with curse words. The aide came out of the room and the resident yelled for her to open the door. The aide yelled something and went back into the room and loud - very loud door slam was heard. This statement indicated the Medicine Aide was also a witness to the event.Further review of the investigation documentation revealed a signed statement from Medicine Aide #7. This statement revealed the event occurred around 8:00 PM on Sunday 3/29/26. This statement also indicated Resident #21 had turned on the call light and was yelling out that s/he needed help. Prior to NA#9 entering the resident's room, NA #9 was yelling out that she has 30 some residents to take care of also. NA #9 went into the resident's room, and the Nurse and Medicine Aide could hear yelling back and forth, including some cuss words. Medicine Aide also heard a loud door slam and more yelling.On 5/14/26 at 3:02 PM Medicine Aide #7 reviewed his/her statement and confirmed the contents were accurate. Medicine Aide #7 also reported that the NA's voice was different from the residents and that the NA was cussing. Medicine Aide #7 reported that the nurse indicated she would go and take care of the situation. Medicine Aide #7 also reported that she told the nurse she needed to call outside the building. Surveyor clarified with Medicine Aide #7 that she meant the nurse should contact the administrative staff when she said call outside the building.Review of the facility's policy on Abuse, Neglect, Exploitation, or Mistreatment (revision date of 10/23/19) revealed in Component V: Reporting/Response 1. All alleged violations concerning abuse, neglect, or misappropriation of property are reported verbally immediately to the Facility Abuse Coordinator, the Administrator and to other officials in accordance with state law including the State Surve and Certification Agency.Further review of the initial report revealed the incident occurred on 3/29/26 at 7:30 PM but was not reported to the administration until 11:00 PM.Further review of the Abuse policy revealed in Component VII: Protection 1. During the investigation, the facility protects the patient/resident , as appropriate, including but not limited to the following: A. Removal of the alleged abuser from the patient/resident care setting.Review of the staffing schedules revealed nursing assistant's evening shifts are from 2:00 PM until 10:00 PM. Review of the timecard documentation for NA #9 revealed a punch in on 3/29/26 at 4:00 PM and out at 10:15 PM. Review of the facility investigation documentation revealed a Corrective Action Form, dated 4/2/26, for Nurse #6 due to Did not intervene when GNA [geriatric nursing assistant] was verbally inappropriate to a resident in a timely manner.Review of a 3/30/26 progress note written by the Director of Nursing (DON) revealed: .The ADON [Assistant Director of Nursing] and I spoke to [name of Resident #21] this AM and s/he denies that the GNA or s/he had used foul language but that the GNA did raise her voice, slam the door and his/her feelings were hurt.On 4/1/26 Nurse #8 wrote: Resident had periods of crying during evening shift. When asked what's wrong, [s/he] stated that an aide from a couple of days ago yelled at [him/her] and cussed [him/her] out. When asked if [s/he] reported this incident, [s/he] stated that, yes, [s/he] did.On 4/1/26 Social Worker #4 wrote: This writer met with [name of Resident #21] on 3/30 and again on 3/31/26 to assess psychosocial well being and discuss concerns stemming from verbal abuse allegation. [Resident name] presented as tearful; anxious; and stated [his/her] feelings are hurt as [s/he] never expected something like that to happen with that particular staff member, whom [s/he] felt was [his/her] friend. [resident name] reports [s/he] was up at 5am Monday night until Tues morning thinking about what happened, and what [s/he] could do to fix the situation.Review of the 4/2/26 Facility Reported Incident (FRI) Follow-Up Investigation Report Form for FRI # 2967650 revealed a verified allegation of verbal abuse. This form included the following statement: All parties indicate that [NA #9] was very loud when speaking to resident and spoke to [him/her] in an inappropriate manner. NA #9 was terminated from employment and a complaint was filed with the board of nursing.On 5/11/26 at 10:52 AM when asked about abuse, Resident #21 reported: I am legally blind, so an incident happened. I activated my call bell, and this staff member, who had been my friend, came to answer it. She said, F you, and the other staff heard her, and she got reported. I was concerned about my safety if she returned to work, so I was okay when she got fired because I feel safe here.On 5/15/26 at 10:44 AM surveyor reviewed with Director of Nursing and the Nursing Home Administrator (NHA) the concerns regarding the failure to ensure the resident was free from abuse, failure to ensure staff reported the abuse in a timely manner to the NHA and that the perpetrator was not removed from resident care prior to the regularly scheduled end of shift.

Based on observation, interview and record review it was determined that the facility failed to ensure medications were labeled in accordance with currently accepted professional principles and failed to store all medication in locked compartments. This was found to be evident on one of the two nursing units.The findings include:1.On 5/13/26 at 10:54 AM observation of the 3rd floor medication storage room with Nurse #12 revealed two cups sitting on top of the medication cart. One cup contained the outer portion of capsules that had already been opened and the other cup was full of a brownish liquid. Nurse #12 reported the liquid was med pass (a nutritional supplement) in the cup and proceeded to throw out both of the cups. Nurse #12 then unlocked the medication cart and surveyor observed a medicine cup with about 5 medications sitting in the top drawer. There was no label to identify these medications or to identify who they were for. Nurse #12 reported they were for Resident #20 but the resident did not want them and indicated she had offered multiple times. Nurse #12 then proceeded to throw out the medications and denied that any were narcotics.On 5/13/26 at 11:50 AM review of the Medication Administration Record for Resident #20 revealed Nurse #12 had documented documented that the Med Pass was administered as ordered at 9:00 AM. The nurse had also documented, at 9:57 AM, that the resident had refused the seven medications that were due to be administered by mouth at 9:00 AM. 2. On 5/13/26 review of previously provided documentation from the facility in regard to medication storage areas revealed medications were stored in a nursing supply room on the first floor.On 5/13/26 at approximately 11:00 AM when surveyor asked the corporate nurse #11 about a nursing supply room on the first floor she indicated she was not aware of one. Surveyor and corporate nurse then asked the Nursing Home Administrator (NHA) who reported no medications were stored on the first floor but that some over the counter (OTC) medications were stored in the Assistant Director of Nursing's (ADON) office in a cabinet.On 5/13/26 at 11:10 AM observation, with corporate nurse #11, revealed the ADON's office was located on the third floor across from the nursing station. The office door was not locked. There was a metal cabinet, approximately 5.5 feet in height, located in the ADON's office. There was a metal latch holding the door shut which was able to be unlatched by hand. There was a key hole in the handle of the door but surveyor and corporate nurse were able to open the cabinet without a key. The cabinet contained multiple OTC medications including but not limited to: aspirin; Senna (laxative/stool softner); bottles of liquid iron; Pepcid; cough drops; milk of magnesium; and suppositories.Review of a list provided by the facility revealed more than 20 of the resident's on the third floor have a diagnosis of dementia.On 5/15/26 at 10:44 AM surveyor reviewed with Director of Nursing (DON) and NHA the concerns regarding the failure to ensure medications kept in the medication cart were labeled and failure to ensure OTC meds were kept in a locked area. The DON reported there was now a lock on the cabinet.

Based on interviews, observations, and record review, the facility failed to implement and maintain an effective Quality Assurance and Performance Improvement (QAPI) program for its water management and Legionella mitigation processes. These failures could affect all residents of the facility who may be exposed to the facility's water system.The findings include:Legionella is a waterborne bacteria associated with respiratory illness and pneumonia-like infections, particularly in vulnerable populations residing in healthcare facilities.On 5/13/26 at 11:40 AM, an interview was conducted with Staff #14, the Maintenance Director, regarding the facility's water management and Legionella prevention processes. Staff #14 stated that maintenance requests are primarily verbal, acknowledged that only limited staff utilize the facility's electronic tracking system, and confirmed that routine shower flushing was not consistently performed or documented. Staff #14 stated that resident room showers were generally not utilized and reported that no routine flushing log was maintained for those showers. Staff #14 also confirmed awareness that the facility had previously experienced Legionella concerns.On 5/13/26 at 11:52 AM, Staff #14 further stated that showers in resident rooms were not routinely flushed unless an odor complaint was received, and acknowledged that there was no documentation log to verify flushing practices. Staff #14 confirmed that some showers containing stored resident belongings would not be flushed.On 5/13/26 at 12:10 PM, Staff #15, the Environmental Services Director, expressed uncertainty about water flushing logs and stated he had only recently been informed that staff were supposed to flush sinks daily. During the same interview, Staff #16, Housekeeping Staff, stated that staff were expected to run water in rooms daily for approximately 10 minutes and reported that they completed the logs submitted monthly. Staff #16 further stated that not all resident room showers were flushed and acknowledged some showers were non-functional.On 5/13/26 at 12:17 PM, Staff #14 acknowledged flushing logs existed but had not initially been provided during the survey process.On 5/13/26 at 12:24 PM, the Nursing Home Administrator (NHA) confirmed awareness of prior Legionella concerns within the facility occurring in December 2025 and acknowledged a second Legionella-related concern had occurred thereafter. The NHA stated that all resident room showers, except one, had been turned off, but was unable to confirm whether showers were routinely flushed.On 5/13/26 between 12:38 PM and 12:47 PM, surveyors observed inconsistent conditions in resident room showers, including some showers running, others off, and dust accumulation on fixtures, indicating a lack of regular use. Residents interviewed stated they received showers in hallway bathing rooms rather than in their resident rooms.On 5/13/26 at 3:09 PM, Staff #3, the Infection Preventionist, stated that the facility only tested residents diagnosed with pneumonia for Legionella, despite guidance directing testing of residents with respiratory illness symptoms. Staff #3 stated that she believed the guidance applied only to residents diagnosed with pneumonia.On 5/13/26 at 3:40 PM, Staff #11, Regional Director of Clinical Operations, and the NHA acknowledged concerns related to Legionella mitigation practices, flushing documentation, and failure to follow guidance regarding resident testing for Legionella-associated respiratory symptoms.On 5/13/26 at 4:15 PM, the surveyor reviewed email guidance from the Allegany County Health Department with Staff #3 dated 1/8/26, which directed the facility to test residents with pneumonia-like or respiratory symptoms for Legionella. Staff #3 acknowledged she had misinterpreted the guidance.On 5/13/26 at 4:22 PM, Staff #14 confirmed there was no comprehensive log identifying which showers were active or shut off and acknowledged there was no routine flushing process for resident room showers. Review of housekeeping flushing checklists revealed flushing documentation was incomplete, inconsistently performed, lacked complete dates and staff identifiers, and did not demonstrate daily flushing practices as identified in the facility's water management plan.During the same interview, Staff #14 acknowledged ongoing concerns about water temperatures and stated that they frequently required several minutes of run time before reaching approximately 100 degrees Fahrenheit.On 5/14/26 at 9:54 AM, the survey team identified ongoing systemic concerns regarding water temperatures and the implementation of the facility's Legionella prevention and water management program. The review indicated that the facility had previously identified Legionella concerns during the 2025 annual survey and had submitted a plan of correction outlining monitoring and mitigation measures.On 5/14/26 at 11:55 AM, Staff #11 stated the Legionella concerns should have been addressed through the facility's Quality Assurance and Performance Improvement (QAPI) process, but was unable to confirm or provide evidence that the issue had been formally incorporated into the facility's QAPI program prior to the start of the annual recertification survey.Guidance from the Allegany County Health Department on 1/8/26 and the facility's water management resources directed the facility to test residents with respiratory illness symptoms for potential Legionella infection.On 5/15/26 at 11:00 AM, the NHA and Director of Nursing confirmed concerns existed regarding the facility's water management and Legionella mitigation processes. They further confirmed that the facility had not implemented a formal testing protocol or an ongoing data collection process for respiratory illness surveillance or Legionella mitigation efforts prior to the start of the annual recertification survey.Refer also to F880.

Based on observation and interview with facility staff, it was determined that the facility failed to ensure proper airflow in the soiled laundry rooms. This was evident from the tours of the soiled laundry rooms conducted during the annual survey.The findings include:Airborne transmission occurs when pathogens are so small that they can be easily spread in the air, and because of this, there is a risk of transmitting the disease through inhalation. These small particles containing infectious agents may be spread over long distances by air currents and may be inhaled by individuals who have not had face-to-face contact with (or been in the same room with) the infectious individuals. According to the Centers for Disease Control and Prevention (CDC), preventing the spread of pathogens that are transmitted by the airborne route requires the use of special air handling and ventilation systems. On 05/12/2026 at 11:00 AM, the surveyor conducted a tour of the clean and soiled laundry rooms alongside the Healthcare Services Group Environmental Services Director. During the tour, a strong odor was noted in the soiled laundry rooms due to absence of negative pressure airflow from the mechanically operated ventilation systems serving the two soiled laundry rooms. At 3:00 PM, a follow-up tour of the laundry rooms was conducted with the Maintenance Director. During the tour, it was observed that a window in one of the soiled laundry rooms was open to provide air circulation. An interview with the Maintenance Director revealed that the roof exhaust fans would be reassessed to ensure proper airflow from the mechanically operated ventilation systems.

Based on record reviews, interviews, and observations, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNAs) received education based on annual performance evaluations and that GNAs received the federally required 12 hours of annual education and in-service training. This was evident for 2 (GNA #17 and GNA #18) of 2 reviewed for annual education while performing the staffing task.The findings include:On 5/13/26 at 6:18 PM, the surveyor reviewed employee records and identified that the most recent performance evaluation for GNA #17 was completed on 7/12/24 and the most recent performance evaluation for GNA #18 was completed on 10/9/24. Both evaluations had exceeded one year since completion.Further review of GNA #18's education training record revealed that GNA #18 had only completed 9.5 hours of training over the past year. Additionally, because a performance evaluation had not been completed, the GNA's (#17 and #18) had not received training assignments based on identified performance needs.On 5/14/26 at 9:28 AM, the surveyor interviewed the Human Resources and Payroll Associate (HR #19) regarding the process for ensuring staff receive required education and performance evaluations. HR #19 stated that she is responsible for ensuring staff are assigned classes that are predetermined by corporate.When asked how the facility ensures staff remain current with required training, HR #19 stated that she sends reports to supervisors when staff are behind on training and posts a list in the breakroom identifying staff who are delinquent in required courses. HR #19 showed the surveyor a bulletin board titled Education Station. The surveyor observed a list of staff that identified the percentage of assigned course completion. The surveyor observed that GNA #18 was listed in red and identified as only 33.33% complete with required courses. HR #19 confirmed that GNA #18 was behind on her annual training.On 5/14/26 at 11:11 AM, the surveyor interviewed the Nursing Home Administrator (NHA), who confirmed awareness that GNA #18 was behind on required training and that the facility had identified it was behind on annual GNA performance evaluations and was working to bring them into compliance. The NHA confirmed that training assignments are expected to be based on each GNA's performance evaluation.Cross Reference F730

Based on record reviews, interviews, and observations, it was determined that the facility failed to ensure that Geriatric Nursing Assistants (GNAs) received annual performance evaluations and that GNAs received the federally required 12 hours of annual education and in-service training. This was evident for 2 (GNA #17 and GNA #18) of 2 reviewed for annual performance evaluations and for 1 (GNA #18) of 3 annual education and in-service records reviewed while performing the staffing task.The findings include:On 5/13/26 at 6:18 PM, the surveyor reviewed employee records and identified that the most recent performance evaluation for GNA #17 was completed on 7/12/24 and the most recent performance evaluation for GNA #18 was completed on 10/9/24. Both evaluations had exceeded one year since completion.Further review revealed that GNA #18 had not completed abuse, Quality Assurance Performance Improvement (QAPI), or compliance training for greater than one year. Additionally, because a performance evaluation had not been completed, the GNA had not received training assignments based on identified performance needs.On 5/14/26 at 9:28 AM, the surveyor interviewed the Human Resources and Payroll Associate (HR #19) regarding the process for ensuring staff receive required education and performance evaluations. HR #19 stated that she is responsible for ensuring staff are assigned classes that are predetermined by corporate.When asked how the facility ensures staff remain current with required training, HR #19 stated that she sends reports to supervisors when staff are behind on training and posts a list in the breakroom identifying staff who are delinquent in required courses. HR #19 showed the surveyor a bulletin board titled Education Station. The surveyor observed a listing of staff that identified the percentage of assigned course completion. The surveyor observed that GNA #18 was listed in red and identified as only 33.33% complete with required courses.HR #19 stated that the Director of Nursing (DON) is responsible for completion of performance evaluations. HR #19 further stated that QAPI training is completed on paper; however, she was unable to provide evidence that GNA #18 had completed QAPI training.On 5/14/26 at 11:11 AM, the surveyor interviewed the Nursing Home Administrator (NHA), who confirmed awareness that GNA #18 was behind on required training and that the facility had identified it was behind on annual GNA performance evaluations and was working to bring them into compliance. The NHA confirmed that training assignments are expected to be based on each GNA's performance evaluation.

Based on observations, interviews, and record review, the facility failed to follow infection control practices for 3 residents (Residents #12, #2, and #7) out of a universe of 3 residents reviewed for infection control. Staff did not perform hand hygiene, did not change gloves when required, did not keep clean and dirty items separate, did not follow safe medication administration practices, and did not follow safe catheterization procedures. These failures placed residents at risk for infection, cross contamination, and harm.Review of facility policy, titled Hand Hygiene/Handwashing dated 2022 documented, Hand Hygiene/Hand washing is the most important component for preventing the spread of infection. Maintaining clean hands is important for patients/residents/visitors as well as staff .Procedures: 1. Hand hygiene/hand washing is done: Before: A. Before patient/resident contact .After: A. After contact with soiled or contaminated articles, such as articles that are contaminated with body fluids. B. After patient/resident contact. C. After contact with a contaminated object or source where there is a concentration of microorganisms, such as, mucous membranes, non-intact skin, body fluids or wounds. D. After toileting or assisting others with toileting, or after personal grooming .H. After removal of medical/surgical or utility gloves .If glove hands become contaminated as gloves are changed hands can be washed. I. Contact with a patient's/resident's intact skin (e.g. taking a pulse or blood pressure, performing physical examinations, lifting the patient/resident in bed. J. Contact with environmental surfaces in the immediate vicinity of patients/residents .2. Wash hands: .C. Before putting on gloves, when changing into a fresh pair of gloves, and immediately after removing gloves. Review of medical records for Resident #12 revealed admission: [DATE] a diagnoses that included type 2 diabetes and need for help with personal care. A Care plan: that showed the resident was always incontinent, had a colostomy, and was at risk for repeated urinary tract infections. Bathing orders: for Wednesday and Sunday, day shift. On 3/5/26, the resident received a partial bed bath with total staff assistance. Perineal hygiene assessments on 3/4/26 and 3/5/26 showed substantial to maximal assistance was required.An observation of incontinence care for Resident #12 on 3/5/26 from 10:51 a.m. to 11:15 a.m. showed: The Geriatric Nursing Assistant (GNA)C touched the bedside table, the blanket covering the resident, dirty linen, closet handles, and clean linen without changing gloves. The GNA handled clean towels, clean sheets, and the faucet with the same gloves used for dirty items. GNA C did not know whether the resident remained on enhanced barrier precautions. The GNA used wet towels removed from the trash bin to clean the resident's genital area. The GNA placed used towels on clean surfaces, including the clean sheet next to the resident. The GNA continued care tasks, including wiping between the buttocks and washing the thighs and knees, without changing gloves. After applying prescription zinc cream, the GNA touched the bedside table with contaminated gloves. At 11:12 a.m., the GNA removed gloves and gown, placed them in the trash, did not wash hands, and exited the room. At 11:15 a.m., the GNA re entered the room, put on gloves, and washed the resident's face.In an interview with the Regional Ombudsman (RO O) on 3/4/26 at 10:02 a.m. reported ongoing concerns about quality of care, agency staff not knowing routines, slow call light response, and staff sharing personal staffing issues with residents. Nurse Manager Licensed Practical Nurse (LPN) B on 3/5/26 at 11:19 a.m. stated staff were expected to wipe front to back, change gloves between dirty and clean tasks, wash hands, and gather all supplies before starting care. LPN B confirmed Resident #12 was on enhanced barrier precautions due to a colostomy.The Director of Nursing (DON) on 3/5/26 at 3:34 p.m. confirmed staff were expected to change gloves, wash hands or use hand sanitizer, and follow clean to dirty steps during care.A record review of Resident #2 showed and admission date of 1/15/25, and documented diagnoses that included spinal stenosis, bilateral lower-extremity weakness, vertigo, muscle weakness, neuropathy, and bone disorder.An observation of medication administration for Resident #2 on 3/4/26 at 7:40 a.m. revealed: Licensed Practical Nurse (LPN) A did not perform hand hygiene before entering the room. LPN A did not sanitize hands before putting on gloves. The LPN administered 11 medications without performing hand hygiene between tasks. During insulin preparation, the right glove ripped, and LPN A continued the procedure with only the left hand gloved. With a bare hand, LPN A wiped the injection site with alcohol and administered the insulin injection. The LPN did not wash or sanitize hands after glove removal.Review of Resident #7's medical record noted the resident was admitted on [DATE]. Resident #7's diagnoses included: Active progressive multiple sclerosis, paraplegia, adult failure to thrive, personal history of urinary tract infections, vitamin B12 deficiency anemia, pain, unspecified Osteoarthritis, unspecified site, neuromuscular dysfunction of the bladder.The Grievance Log documented a care concern reported on 2/12/26, which the facility marked as resolved on 2/19/26. The Minimum Data Set (MDS) showed: Quarterly MDS dated [DATE]: BIMS score of 15; toileting hygiene was dependent; urinary continence was always incontinent. Annual MDS dated [DATE]: BIMS score of 15; toileting hygiene was dependent; urinary continence was always incontinent. The Care Plan documented: The resident reported signs and symptoms of a urinary tract infection even when urine tests were negative and requested antibiotics.The resident was at risk for negative psychosocial outcomes related to expressing multiple care concerns and making an allegation of abuse.The resident showed mild changes in cognitive function, including problems with information processing, attention, and concentration, and showed cognitive biases toward staff related to multiple sclerosis. The resident had altered urinary elimination related to multiple sclerosis and neurogenic bladder, with a history of repeated urinary tract infections and incontinence. Physician orders showed the resident required toileting with the help of 1-2 staff. Progress notes included: 12/31/25: A catheterization was attempted for a urine culture. Very little urine was obtained, not enough for testing. The resident asked to continue the ordered antibiotic (Macrobid 100 mg twice a day for 7 days) and refused another catheterization. The provider was notified and discontinued the urine culture order. 12/28/25: The resident reported seeing fecal matter on the tip of the catheter and stated it had been inserted into the urethra with fecal matter on it. The nurse documented that she reassured the resident this was not true, but the resident continued to state otherwise. 12/28/25: A urine sample was obtained by straight catheterization. The urine was dark yellow and concentrated, and the resident tolerated the procedure.A review of the complaint and facility reported incident based on the same situation noted that Resident #7 reported that during a straight catheterization for a urine sample, Registered Nurse F: Touched the wrong area and poked near the anus while trying to find the urinary opening.Inserted the catheter into the vagina, and the resident shouted that it was the wrong place. Then inserted the catheter into the urinary tract, which caused pain. Pressed on the resident's abdomen to obtain more urine, even after the resident said it hurt. Stated that the catheter came out and ended the procedure. The resident reported feeling upset, in pain, and distressed by the procedure and stated they did not want that nurse to care for them again. In an interview with the Social Services (SOC) G on 3/5/26 at 2:30 p.m. they stated that Resident #7 reported the allegation by email; the Social Worker did not recall the exact date but felt the email needed to be sent to the Director of Nursing and Administrator for investigation. The resident reported that the catheter was placed in the anus. Resident #7 appeared upset and frustrated and felt that RN F should have been able to perform the procedure correctly. The resident stated that they did not want RN F to perform procedures or engage with that nurse again. The resident's description of the event stayed consistent in repeated conversations with the Social Worker. Resident #7 was alert and oriented and had a BIMS score of 15. The Social Worker described the resident as sometimes difficult to investigate because they brought up past issues that had already been resolved. The Social Worker met with the resident several times, monitored psychosocial status, and stated that re education for the nurse was done and communicated to the resident. Advocacy and counseling services were offered; the resident declined. When the resident was adamant about not wanting certain staff, those staff were removed from that assignment to support the resident's sense of safety.In an interview with the Infection Preventionist / Staff Development (RN) E on 3/5/26 at 2:58 p.m. The Infection Control Staff Development Coordinator stated: They were asked by administration to provide an in service on straight catheterization for RN F. A mannequin was used and the nurse demonstrated the procedure and did it perfectly, and RN E had no concerns at that time. RN E reported that an infection control boot camp for staff had been provided, including isolation types, personal protective equipment, and hand washing, and did this for new hires and agency staff. They had also in serviced the GNA C on perineal care, including Hand sanitizing and gathering all equipment before care. Working from outer to inner areas, front to back. Not using dirty washcloths or linens again. Changing gloves after dirty care and between new briefs.Hand sanitizing or washing hands before putting on gloves and after gloves were torn or soiled. RN E stated that the expectations for medication pass included hand hygiene before/after, between residents and washing hands when visibly soiled. RN E was not sure when the last incontinence care in service had been done.An interview with the DON on 3/5/26 at 3:34 p.m. revealed the DON first became aware of the resident's allegation after the Social Worker shared the resident's email following a holiday weekend. Resident #7 reported that the nurse placed the catheter in the rectum, then the vagina, and then the urethra, and that the resident was particular about how far her legs could be spread due to prior injuries. The nurse reported that the catheterization was difficult because the resident would not allow her to spread the legs fully. The facility interviewed the resident, the nurse, and the aides present and told the nurse they would receive competency checks. The DON stated that RN F had performed many catheterizations and usually worked night shift. When asked the DON did not know when the nurse's last catheterization competency was completed. The DON stated that catheterization was a sterile procedure and that the expectation was to keep the procedure as clean and sterile as possible, with clean gloves and careful technique. They reported that when the resident did not want the nurse to care for them, the DON followed up with RN F and told the nurse that the resident did not want RN F assigned to them. The DON stated they were aware that the nurse had returned to the resident's room after the event to retrieve the catheter from the trash after being told it should not have been thrown away, and that this was not consistent with how the DON would have expect the procedure to be handled.

Based on observation, interviews, and record review, the facility failed to give clean and safe incontinence care for 1 resident (Resident #12) out of a universe of 1 resident reviewed for incontinence care. The staff did not keep clean and dirty items separate, did not change gloves when needed, did not follow hand hygiene steps, and did not follow enhanced barrier precaution rules. This failure placed the resident at risk for infection.Review of facility nursing policy and procedures titled, Perineal and Incontinence Care dated 5/5/23 documented, Using gentle downward strokes, clean from the front to the back of the perineum to prevent intestinal organisms from contaminating the urethra or vagina. Avoid the area around the anus and use a clean section of wash cloth for each stroke by folding each used section inward .If you're using soap and water, wet a clean washcloth and rinse the perineum thoroughly from front to back, because soap residue can cause skin irritation. Pat the area dry with a bath towel .Clean, rinse, and dry the anal area, starting at the posterior vaginal opening and wiping from front to back .Gather and prepare the necessary equipment and supplies. Perform hand hygiene .Raise the patient's bed to waist level before performing care .Perform hand hygiene. Put on gloves, gown, and mask, as needed, to comply with standard precautions.Review of the medical record for Resident #19 revealed an admission date: 4/9/24. Diagnoses included type 2 diabetes and need for help with personal care. The care plan documented the resident was always incontinent, had a colostomy, and was at risk for repeated urinary tract infections. Bathing orders: Wednesday and Sunday, day shift. On 3/5/26, the resident received a partial bed bath with total staff assistance.Perineal hygiene assessments on 3/4/26 and 3/5/26 showed the resident required substantial to maximal assistance.On 3/5/26 from 10:51 a.m. to 11:15 a.m., an observation of incontinence care for Resident #12 showed: The Geriatric Nursing Assistant (GNA) C touched the bedside table, the blanket covering the resident, dirty linen, closet handles, and clean linen without changing gloves. GNA C handled clean towels, clean sheets, and the faucet with the same gloves used for dirty items. The GNA did not know whether the resident remained on enhanced barrier precautions. GNA C used wet towels removed from the trash bin to clean the resident's genital area. The GNA placed used towels on clean surfaces, including the clean sheet next to the resident. The GNA continued care tasks, including wiping between the buttocks and washing the thighs and knees, without changing gloves. After applying prescription zinc cream, the GNA touched the bedside table with contaminated gloves. At 11:12 a.m., the GNA removed gloves and gown, placed them in the trash, did not wash hands, and exited the room.At 11:15 a.m., the GNA re entered the room, put on gloves, and washed the resident's face.During an interview with the Regional Ombudsman (RO O) on 3/4/26 at 10:02 a.m. reported ongoing concerns about quality of care, agency staff not knowing routines, slow call light response, and staff sharing personal staffing issues with residents.During an interview with the Nurse Manager (Licensed Practical Nurse) LPN B on 3/5/26 at 11:19 a.m. stated staff were expected to know the steps of incontinence care, including wiping front to back, changing gloves between dirty and clean tasks, washing hands, and gathering all supplies before starting care. LPN B confirmed Resident #12 was on enhanced barrier precautions due to a colostomy.In an interview with Director of Nursing (DON) on 3/5/26 at 3:34 p.m. stated staff were expected to change gloves, wash hands or use hand sanitizer, and follow clean to dirty steps during care.

Based on interview, record review, and facility document and policy review, the facility failed to revise the care plan for 1 (Resident #14) of 9 residents reviewed for care plans. Specifically, the facility failed to revise Resident #14's care plan to include a history of drug abuse and an incident when the resident was found unresponsive and positive for fentanyl (a potent opioid drug), which was not prescribed for the resident.Findings included:A facility policy titled, Care Plan Process, Person-Centered Care, revised 05/05/2023, indicated, 6. The Interdisciplinary Team (IDT) will review for effectiveness and revise the person-centered care plan after each assessment. This includes both the comprehensive and quarterly assessments. The policy also revealed, 9. Thru [sic] ongoing assessment, the facility will initiate person-centered care plans when the resident's clinical status or change in condition dictates the need such as but not limited to falls and pressure ulcer development. A Resident Face Sheet indicated the facility admitted Resident #14 in April 2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of hemiplegia and hemiparesis following cerebral infarction (stroke), hepatic encephalopathy, dysphagia, aphasia, and vascular dementia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/2025, revealed Resident #14 had moderate impairment in cognitive skills for daily decision-making and had a short-term memory problem per a Staff Assessment of Mental Status (SAMS). Resident #14's nursing Resident Progress Notes, dated 03/11/2025 at 6:06 PM revealed staff found the resident unresponsive, not responsive to voice, touch, or a sternal rub. A Facility Reported Incidents Initial Report Form, dated 03/12/2025, revealed Resident #14 was found unresponsive on 03/11/2025 at approximately 6:06 PM. The form revealed nursing staff notified the physician, who ordered the resident to be transferred to the emergency room (ER). The form revealed that at the hospital, the resident was positive for fentanyl; however, the resident was not prescribed the medication while in the facility. Resident #14's emergency room (ER) Observation Note, dated 03/11/2025, indicated the resident was unresponsive and emergency medical services (EMS) administered Narcan (a medication that rapidly reverses the effects of an opioid overdose), and the resident's symptoms improved. The note revealed that the resident's urine screen dated 03/11/2025 was positive for fentanyl. According to the ER Observation Note, Resident #14 had a history of drug abuse, and past medical history included a stroke secondary to a suicide attempt/overdose. A Facility Reported Incident Follow-Up Investigation Report, dated 03/19/2025, revealed the facility educated staff on the signs/symptoms of opioid over consumption and the facility would review the resident's progress notes and vital signs as part of their clinical morning stand-up meetings. Resident #14's Care Plan, last reviewed/revised 10/11/2025, revealed no documented evidence the facility revised the resident's care plan to address the resident's history of drug abuse or the 03/11/2025, ER visit when the resident tested positive for fentanyl, a medication they were not prescribed. During an interview on 10/23/2025 at 10:57 AM, the MDS Coordinator stated there was no reason Resident #14's care plan was not updated with their history of drug abuse or testing positive for fentanyl.During an interview on 10/22/2025 at 12:27 PM, the Assistant Director of Nursing (ADON) stated she did not know why Resident #14's history of drug abuse and the fentanyl incident were not on the resident's care plan. During an interview on 10/22/2025 at 3:08 PM, the Director of Nursing (DON) stated Resident #14's history of drug abuse and the incident of testing positive for fentanyl should have been added to the resident's care plan. During an interview on 10/22/2025 at 3:46 PM, the Administrator stated after the incident they monitored family visits for a while; however, Resident #14's care plan was not revised because it was a one-time incident, and there had been no incidents since.

Based on observation, interview, and facility policy review, the facility failed to ensure staff donned all required personal protective equipment (PPE) prior to providing incontinence care and failed to ensure staff followed the facility's hand hygiene policy/procedure for 1 (Resident #8) of 1 resident reviewed for infection control.Findings included:A facility policy titled, Transmission Based/Standard Precautions, and Enhanced Barrier Precautions (EBP), revised 05/15/2023, revealed, B. EBP will be implemented during the following high-contact resident care activities: 1) Dressing, 2) Bathing/showering, 3) Transferring, 4) Providing hygiene, 5) Changing linens, 6) Changing briefs or assisting with toilet, 7) Device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator. The policy further revealed, C. EBP requires the following PPE: 1) Gloves, 2) Gown, and 4) All PPE is donned and doffed with appropriate hand hygiene and disposable [sic] after individual use or when visibly soiled.A Resident Face Sheet revealed the facility admitted Resident #8 on September 2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of infection and inflammatory reaction due to other urinary catheter and need for assistance with personal care.An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/24/2025, revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident had an indwelling catheter and was dependent on staff for toileting hygiene.Resident #8's Care Plan, included a problem statement initiated 09/18/2025, that indicated the resident had an indwelling urinary catheter. Interventions directed staff to follow appropriate infection precautions during care, including EBP for residents with a urinary catheter (initiated 09/18/2025).During an observation on 10/21/2025 at 10:04 AM, Geriatric Nurse Aide (GNA) #19 and Certified Nursing Assistant (CNA) #20 answered the call light for Resident #8 and the resident requested assistance with incontinence care. Prior to providing care, GNA #19 and CNA #20 did not don a gown, despite signs that were visible on Resident #8's door indicating the resident required EBP. The observation revealed gowns were also visible outside Resident #8's door.During the observation, GNA #19 and CNA #20 donned gloves, and Resident #8 turned toward CNA #20. A large amount of liquid stool was visible on Resident #8's buttocks and lower back. GNA #19 wiped the resident's perineal area from front to back, then washed the resident's buttocks with a wet washcloth. GNA #19 then patted the resident dry with a clean towel. Without changing gloves, with GNA #19's left hand, he grabbed Resident #8's left hand and assisted the resident to turn towards him. The observation revealed CNA #20 wiped stool from the resident's left side, washed the resident's left side with a wet washcloth, and then patted the resident dry with a clean towel. The observation revealed GNA #19 then removed his gloves, washed his hands with soap and water, and applied new gloves. Resident #8 turned onto their back and GNA #19 removed the resident's shirt and washed the resident's right side. With the same gloved hands that were used to clean stool, CNA #20 washed the resident's left side, grabbed the resident's deodorant, and handed the deodorant to GNA #19. GNA #19 applied deodorant to the resident's left armpit and handed it back to CNA #20. CNA #20 applied deodorant to the resident's right armpit and placed the deodorant back on the resident's bedside table. GNA #19 and CNA #20 applied a clean brief and a clean shirt for the resident. Again, with the same gloved hands used to clean stool, CNA #20 used the bed remote to adjust the bed. CNA #20 then removed her gloves for the first time and washed her hands with soap and water. GNA #19 removed his gloves and washed his hands with soap and water before leaving the room.During an interview on 10/21/2025 at 10:44 AM, GNA #19 stated he probably should have put a gown on since Resident #8 had a catheter. GNA #19 stated he also should have changed his gloves and performed hand hygiene more often.During an interview on 10/21/2025 at 10:55 AM, CNA #20 stated she should put on a gown when providing incontinence care to residents on EBP. CNA #20 stated Resident #8 was on EBH, but she was not sure when to wear a gown when providing care to the resident. CNA #20 stated she should have changed her gloves after wiping the resident, but she was nervous.During an interview on 10/22/2025 at 9:13 AM, the Quality Assurance/Infection Prevention (QA/IP) Nurse stated that if a resident had a catheter, the resident was placed on EBP. The QA/IP Nurse stated that staff should wear gloves and a gown when personal care was provided. The QA/IP nurse stated that staff should change gloves if they became soiled and could change gloves at any time. The QA/IP Nurse stated she and the Assistant Director of Nursing (ADON), unit managers, and the Director of Nursing (DON) monitored staff for proper hand hygiene and infection control.During an interview on 10/22/2025 at 10:24 AM, the ADON stated staff were expected to change gloves if they became soiled and before placing a clean brief on the resident. The ADON stated all residents with catheters were on EBP, and staff were expected to wear a gown and gloves when incontinence care was provided to residents on EBP. The ADON stated all staff were expected to monitor whether staff were wearing gowns and was not sure who monitored incontinence care.During an interview on 10/22/2025 at 10:33 AM, the DON stated residents with catheters were on EBP, and staff were expected to wear a gown and gloves when incontinence care was provided to a resident on EBP. The DON also stated gloves should be changed when they were visibly dirty, and she would change them before putting a clean brief on a resident. The DON stated she expected staff to wear the appropriate PPE and follow proper hand hygiene. The DON stated that the QA/IP Nurse monitored staff to ensure EBP and hand hygiene were performed and should monitor to ensure staff followed infection control protocol when providing incontinence care.During an interview on 10/23/2025 at 10:12 AM, the Administrator (ADM) stated she expected staff to wear a gown and gloves if a resident was on EBP and to change gloves between dirty and clean areas. The ADM stated the QA/IP Nurse, and the DON should monitor staff to ensure they followed proper infection control procedures.

Based on record reviews and interviews it was determined the facility staff failed to ensure that licensed nurse coverage was present the entire night shift on 2/21/25. This was evident for 1 (#MD00214955) of 12 complaints reviewed during the survey. The findings include: During an interview on 3/5/25 at 2:26 PM, Resident #2 indicated to a surveyor that s/he felt unsafe. When asked to explain, s/he reported that agency staff who worked overnight 2 weekends ago left the building unattended, to get food. The resident added that no medications were given that evening. s/he was uncertain of the credentials of the staff involved. Review of an anonymous complaint on 3/6/25 alleged that 2 agency LPN's (Licensed Practical Nurses) left the facility for approximately 1-2 hours during the night shift on 2/21/25 to purchase food from a convenience store. The agency LPNs were the only licensed nurses in the facility that night. The absence of the Agency LPNs left the facility resident's and GNAs (Geriatric Nursing Assistants) without supervision of a licensed nurse, and a medication pass was missed. This information was confirmed in an interview with anonymous complainant #37 on 3/6/25 at 2:08 PM. Review of the staffing schedule for 2/21/25 revealed there were 73 residents in the facility on that date, 4 GNAs were working from 10 PM 2/21/25 - 6 AM 2/22/25, the 2 LPNs scheduled for night shift called out and Staff #14 and #15, agency LPNs were added to the schedule in their place. Review of the agency staff timesheets revealed that Staff #14 worked from 8:17 PM on 2/21/25 - 8:26 AM 2/22/25, and Staff #15 worked from 8:15 PM on 2/21/25 - 8:26 AM on 2/22/25. Each timesheet indicated a 30-minute break was taken but did not specify the time of the break. No licensed nurse was designated to serve as the charge nurse. In an interview on 3/7/25 at 9:14 AM Staff #19 a GNA confirmed she worked on the 3rd floor from 10 PM - 2 AM on 2/21/25-2/22/25. When asked if she recalled any issues with staffing that night, she indicated she did. She stated that around 12:00 midnight, the LPN working on the 3rd floor said she was going downstairs. Staff #19 assumed it was for a break. She indicated that about 45 minutes later she walked downstairs because the LPN had not returned. She found that the 2nd floor nurse was also missing. She indicated they didn't come back till about 1:40 AM when she opened the front door to let them in. An interview was conducted with the Administrator on 3/10/25 at 9:40 AM. When asked if there were issues regarding the agency LPNs who worked on the night of 2/21/25, the Administrator stated, I got a report that the LPNs took an excessively long break. She indicated that the agency used Geotracking and according to Geotracker, they took a 40-minute break outside of the geofence. She added, staff are allowed to leave the property for lunch break. When asked if they left at the facility at the same time she stated, that's what I hear. She confirmed there were no licensed staff in the building while the LPNs were gone and that only the 4 GNA's were in the facility providing care for the residents during the time Staff #14 and #15 left. A telephone interview was conducted with agency LPN, Staff #14 on 3/10/25 at 2:33 PM. When asked about the events on 2/21/25 she stated, I got there super late, everything was closed, I didn't have any food, thought we could get food really quick and come back. She confirmed that Staff #15 left the facility with her and stated, we came right back, everything was fine. She indicated that they left the facility at approximately 12:30 PM and believed they returned about 1:00 AM. She confirmed they went to a [NAME] store but did not know where it was located. When asked who was the charge nurse that night she stated, There was no nurse supervisor, it was just me and the other nurse there. She stated what could have really gone wrong? If I didn't get anything to eat I couldn't have continued my shift anyway, I had just driven 4 hours to get there. Cross reference F-684.

Based on records review and interviews, it was determined that the facility failed to ensure allegations of abuse were reported within the mandated time frame. This was evident for 3 (Resident #38, #25, #64) of 6 residents reviewed for abuse. The findings include: 1.)On 3/06/25 at 11:56 AM a review of the facility reported incident (FRI) #MD00214156 was conducted. The report described an allegation that a Geriatric Nursing Assistant (GNA #3) was observed to have forcefully pushed Resident #25 into his/her wheelchair. Further review revealed that the incident was witnessed by the facility social worker (SW #18) and that the incident occurred in the resident dining room on 1/30/25 at 12:15 PM. A review of the facility investigation file revealed that the Nursing Home Administrator (NHA) first reported the incident to the Office of Health Care Quality on 1/30/25 at 4:48 PM. On 3/10/25 at 9:34 AM an interview with the NHA and the Director of Nursing was conducted. The NHA acknowledged that the incident was reported more than 4 hours after it occurred and confirmed the deficiency of the late report. No further information was provided regarding the timeliness of the report. 48470 2.) Resident #38 was admitted to the facility in the 3rd quarter of 2024. A quick look into the resident's medical record indicated intact cognition and that a Facility Reported Incident (FRI) for abuse, related to MD00210264, was investigated by the facility. Resident #38 was interviewed on 3/4/25 at 10:16 AM. During the interview, the resident confirmed the incident and reported that it happened a long time ago. On 3/7/25 at 12:34 PM, the investigation packet for the FRI related to MD00210264 was reviewed. The review revealed that the allegation of abuse was first reported to Geriatric Nursing Assistant (GNA #41) on 9/26/24 at 8 AM. The Abuse coordinator was the Nursing Home Administrator (NHA) and was notified on the same day at 8:30 AM. Further review of the investigation packet revealed that the initial report was sent to the State Agency on the same day (9/26/24), however, the time stamp on the email confirmation indicated that the report was not sent until 5:23 PM. The NHA was interviewed on 3/7/25 at 1:42 PM. During the interview, the NHA was asked if she knew the mandated time frame for reporting allegations of abuse. The NHS stated, I do now! And indicated that it was two hours regardless of if there was serious injury. The NHA confirmed that the initial report for the FRI related to MD00210264 was reported late. 51900 3.) Review of Facility Reported Incident (FRI) #00209595 revealed that on 9/08/24 at 10:00 PM, Resident #64's representative informed facility Nurse #40 of an abuse allegation. The representative reported that on 9/07/24, the Geriatric Nursing Assistant (GNA) was fast and rough when applying a cream and slapped the resident's hand when the resident grabbed the handrail. Nurse #40 notified the Director of Nursing (DON) and the Nursing Home Administrator (NHA) at 10:45 PM on 9/08/24. The facility reported the allegation to the Office of HealthCare Quality (OHCQ) on 9/09/24 at 1:20 PM. Review of the facility policy and procedure titled Abuse, Neglect, Exploitation, or Mistreatment revealed the following: * Report Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury. Report to the Administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. On 3/05/25 at 3:38 PM, the surveyor interviewed the NHA and the DON. The surveyor asked how the facility handled allegations of abuse. They responded that the staff are instructed to notify either the NHA or the DON immediately. The surveyor then asked when they would notify the regulatory agency and they replied, As soon as we know about it. Surveyor then reviewed the concern that this allegation was reported more than two hours after the facility staff was made aware of it. On 3/06/25 at 1:00 PM, the NHA reported they had no additional information to provide regarding this concerns.

Based on record review and staff interview, the facility failed to have a process in place to: 1) ensure that the most current Maryland Medical Order for Life-Sustaining Treatment (MOLST) form was placed in the residents' medical record. This was evident for 1 of 3 residents (Resident #1) reviewed for MOLST. The facility's failure resulted in harm to Resident #1 whose most current MOLST orders had indicated that Cardiopulmonary Resuscitation (CPR) not be performed in the event of [CONDITION(S)]. The failure of staff to follow the most current MOLST order form resulted in CPR being performed on the resident against the resident's wishes by facility staff, Emergency Medical Services (EMS), and hospital staff. The findings include: Physicians Orders for Life-Sustaining Treatment (POLST) [MEDICATION(S)] form is a form designed to improve patient care by creating a portable medical order form that records patients' wishes so that Emergency personnel know what treatments the patient wants in the event of a medical emergency, taking the medical condition into consideration. Advanced Directives is a written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the Stats), relating to the provision of health care when the individual is incapacitated. Maryland MOLST is a portable and enduring form for orders about cardiopulmonary resuscitation and other life-sustaining treatments. (https://marylandmolst.org) 1) A review of the facility's investigation file for the Facility Reported Incident MD 723 on [DATE] at 11:44 AM revealed that the facility determined that Resident #1 had received CPR and was transported to the hospital via EMS with a MOLST form that documented No CPR, Option B, Palliative and Support Care. Review of the progress note written by Registered Nurse (RN) #3 revealed that Resident #1 had been found with no pulse on [DATE]. RN #3 then checked the medical chart for Resident #1's code status and noted a MOLST form that ordered attempt CPR. RN# 3 documented that CPR was initiated, EMS was activated via 911, and Resident #1 was administered CPR by facility staff until EMS staff took over CPR. EMS was able to revive the Resident #1 and transported them to an acute care hospital. Furthermore, RN #3 noted that when a facility night shift nurse reported that Resident #1's code status had been changed to Do Not Resuscitate on an updated MOLST form; they started looking for the updated MOLST form. Per RN #3's progress note, staff had found the updated MOLST form in an Emergency Binder and that it had been updated to no CPR. The facility investigation file had a copy of the MOLST form, dated [DATE], which revealed documentation that, based on the the patient's health care agent Resident #1 would prefer them to, attempt CPR. The file had a copy of a second MOLST form, dated [DATE], with documentation that, based on the the patient's surrogate as per the authority of the Health Care Decisions Act, Resident #1's wishes were for No CPR, Option B, Palliative and Supportive Care. On page two of the MOLST form, the Physician had noted under section 4, that Resident #1 had not wanted to be transferred to the hospital but wished for treatment with options available outside the hospital. The facility's investigation file was missing staff interviews, statements from staff and a summary to document investigation findings. A review of the medical record in Matrix on [DATE] at 4:15 PM for Resident #1 revealed a History and Physical (H&P) conducted by the attending physician on [DATE], which documented Resident #1 had been admitted to the facility following a hospitalization due to a bleeding stomach ulcer and had the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The attending physician had noted MOLST form filled/reviewed. Further review revealed that the one MOLST form uploaded to Matrix was dated [DATE] and there was documentation on Resident #1's Face Sheet that listed the resident's code status as full code (give CPR). On [DATE] at 9:00 AM, a review of Resident #1's closed record revealed that the MOLST form, dated [DATE], had not been voided. In addition, a Certification of Incapacity form had been signed by two physicians on [DATE], which had made the MOLST form, dated [DATE], invalid since the physician had consulted the surrogate decision maker to create the [DATE] dated MOLST form even though Resident #1 had not been deemed incapable at the time the MOLST form had been completed on [DATE]. It was after the [DATE] dated MOLST form was completed that Resident #1 was deemed incapable by two physicians on [DATE]. However, review of the attending physician's visits with Resident #1 on [DATE], [DATE], and [DATE] revealed no documentation by the attending physician that they had reviewed the MOLST form with the surrogate decision maker after the change in capacity forms were completed on [DATE] to ensure accuracy of the MOLST form. During a medical record review for Resident #1 on [DATE] at 4:15 PM, a progress note, dated [DATE], documented that Resident #1 had a COVID-19 test done and was found to be positive for COVID-19. A progress note, dated [DATE], revealed that Resident #1 was transferred to an acute care hospital due to a low blood oxygen level. On [DATE] at 9:00 AM, review of the closed medical record revealed the hospital records for the visit on [DATE]. A discharge summary, dated [DATE], had documentation that Resident #1's family had agreed to change the MOLST form from attempt CPR to No CPR, Option B, Palliative and Support Care. This updated MOLST form was dated [DATE]. In addition, there had been two Certifications for Incapacity signed by two different physicians on [DATE] and [DATE] that had deemed Resident #1 incapable of making healthcare decisions. Furthermore, continued record review revealed Resident #1 had completed an Advanced Directives in 2017 that had named the people Resident #1 had wanted to make healthcare decision for him/her when Resident #1 was determined not to be capable of making those decisions. However, review of progress notes and visit notes revealed there had been no documentation from the attending physician regarding the discussion with the surrogate decision maker about the MOLST form dated [DATE], which had been completed at the local hospital, to ensure the accuracy of the MOLST form. Review of Resident #1's medical record in Matrix on [DATE] at 4:15 PM revealed a progress note, dated [DATE], (twenty days after the updated MOLST form dated [DATE] had been received by the facility), RN #3 documented that Resident #1 had no pulse and the MOLST form on Resident #1's medical chart and in Matrix was not updated to the option No CPR, Option D, palliative and Support that was dated [DATE]. On [DATE] at 9:30 AM, a review of the hospital records for [DATE] for Resident #1 revealed that Resident #1 had presented to the Emergency Department with no pulse and no spontaneous respirations and that EMS had been actively performing CPR. Also, documented had been that the nursing home had called to report Resident #1 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Resident #1 had received an injection of [MEDICATION(S)] 0.1 mg/mL (milligrams/milliliters) which had been a medication administered as a life-sustaining measure. An interview with Director of Social Work (DSW) #4 on [DATE] at 2:30 PM, revealed that the Social Worker's role with the MOLST form for newly admitted and readmitted residents had been to determine if the resident had a MOLST form, educate resident/resident representative about the MOLST form, and prepare and send MOLST form to the physician for review. DSW #4 reported that she had tracked the MOLST form to ensure it had been completed by the physician and then ensured that it had been scanned into the electronic medical record, the original and three copies had been placed in the resident's medical chart, and a copy had been placed in the Emergency Binder. However, DSW #4 had left the facility sometime in [DATE] (DSW #4 had been unable to recall the actual date), so at the time of this incident, with Resident #1, the facility did not have a social worker assigned to manage MOLST forms in the facility. [DATE] at 2:30 PM an interview with RN #3 revealed that, on the day of the incident, she was informed by a Geriatric Nursing Assistant (RN#3 had been unable to recall the name of the Geriatric Nursing Assistant) that Resident #1 was not breathing. RN #3 stated she had gone to Resident #1's room and determined Resident #1 had no pulse. RN #3 confirmed that the MOLST form that was in Resident #1's medical record had been the one dated [DATE], and had indicated to attempt CPR. RN #3 reported that CPR had been initiated and EMS activated via 911. When EMS arrived, RN #3 reported that they took over CPR and had been able to revive Resident #1 to 70 heart beats per minute. RN #3 stated Resident #1 was then transported to the local hospital. RN #3 stated then another staff member mentioned that they thought Resident #1 had orders for No CPR. RN #3 reported that staff looked for an updated MOLST form and found one in the Emergency Binder on the unit. RN #3 confirmed it had been the MOLST form signed on [DATE]. RN #3 stated she had called the local hospital to report the change in status. When asked about the facility's policy on where to look for a MOLST form since it had been placed in several locations, RN #3 reported that she had not been aware of a policy or had received education as to where the facility expected staff to look for MOLST form. RN #3 reported that it had been a standard practice that she had looked at Resident #1's medical chart for the most current MOLST form. An interview with the Nursing Home Administrator (NHA) on [DATE] at 3:23 PM, confirmed that the facility had their long-term Social Worker leave and they had not hired a new one at the time of the incident in [DATE]. When asked who had been assigned the duty to ensure that the MOLST form had been taken care of for new admissions and readmissions, NHA reported that the Unit Managers had been assigned that role. NHA reported that Unit Managers had always been involved with the Social Worker to ensure the MOLST form had been on the chart. NHA reported that the investigation had determined that placing the MOLST form in several different locations may have been the problem. An interview with the Interim Director of Nursing (DON) on [DATE] at 11:06 AM revealed she had been the Unit Manager covering the unit that Resident #1 resided on at the time of the incident. Interim DON reported that, as a Unit Manager, she had been responsible for MOLST forms with new admissions and readmissions. Interim DON stated that, at the time of the incident with Resident #1, the facility had been in an COVID-19 outbreak status. Interim DON had been deemed the clean Unit Manager and had been told not to enter the positive COVID-19 unit during the outbreak. When Resident #1 had returned from the hospital on [DATE], Interim DON had been unable to take Resident #1's medical record and complete a review to ensure that the most current MOLST form was placed in the chart. When asked who was expected to ensure that the MOLST form had been placed on the chart, Interim DON reported that the nurse assigned to the admission would have been expected to take care of the MOLST form. However, the DON and NHA had not been aware of who the admitting nurse had been or why the new MOLST form had not been placed in Resident #1's record at the time of readmission. NHA and Interim DON had been made aware of concerns on [DATE] at 11:00 AM.

Based on complaint and a facility reported incident, reviews of an active and closed medical record and staff interview, it was determined the facility staff failed to 1) provide a safe environment by using a broken shower chair which led to the resident (#1) falling and suffering a fractured leg, and 2) provide a resident with enough supervision to ensure the effectiveness of nursing interventions to prevent the resident (#6) from continued falls. This occurred for 2 of 6 (Resident #1, Resident #6) residents reviewed during a complaint survey. The findings include: 1) 1) Review of complaint MD 585 on 07/19/16 revealed an allegation that Resident #1suffered a fractured foot while in the shower on 03/03/16. Review of the facility investigation into Resident #1's foot fracture revealed that, on 03/03/16 at approximately 9:45 PM, Resident #1 sustained a fall. Subsequent X-rays determined that Resident #1 had suffered a right distal fibula fracture. Further review of the facility investigation revealed a witness statement by GNA #1 which indicated that, during the transfer of Resident #1 out of the shower chair, Resident #1 reached back with his/her right hand to grab the shower chair and the shower chair was pulled off the wall and rolled into the shower. This is when Resident #1 fell to the ground. GNA #1 also stated that he/she knew the shower chair breaks did not lock and that the shower chair had been broken for 2 months. GNA #1 also stated that he/she did not typically use that particular shower chair, but used the shower chair with Resident #1 because there was no other shower chairs available. In an telephone interview on 07/22/16 at 10 AM, the surveyor read GNA #1's 03/10/16 witness statement regarding Resident #1's fall on 03/03/16 at 9:45 PM to him/her and GNA #1 acknowledged that was what had happened when Resident #1 fell in the shower room. The nursing staff must provide a safe environment by using properly functioning equipment to prevent residents from falling. The facility conducted an investigation, identified nonfunctioning shower equipment, purchased new shower equipment, and in-serviced the nursing staff. This citation was determined to be past non-compliance with a plan of correction in place with a date of 03/24/16. This occurred prior to this complaint survey. 2) Review of facility reported incident MD 884 on 07/20/16 revealed that Resident #6 had sustained a fall on 02/08/16 at approximately 6:50 AM and was sent to the emergency room and admitted with a head concussion. Upon readmission to the facility on [DATE], the nursing staff initiated the following fall prevention interventions which included: adding anti-rollbacks to the wheel chair, adding a bed alarm, placing Resident #6 on a toileting program, and have Resident #6 evaluated by rehabilitation services. Further review of Resident #6's medical record revealed that Resident #6 had another fall on 02/18/16 at 3:30 PM while resting at the nurses' station and was sent to the emergency room for evaluation. Reviews of the post fall incident report indicated the nursing staff again updated fall prevention interventions to include a psychiatry evaluation, placing hipsters on the Resident #6, and adding a break away lap buddy. Further review of Resident #6's medical record revealed that Resident #6 had another fall on 02/24/16 at 10:30 PM in front of the elevator. The incident report indicated Resident #6 slid out of his/her wheel chair and fell face first onto the floor hitting the right side of the head producing a golf ball size hematoma and a right hand laceration to a knuckle. The incident report indicated that Resident #6 had removed his/her chair alarm. Resident #6 fell three times between 02/08/16 thru 02/24/16, each requiring a hospital visit. The surveyor determined that the nursing staff were unable to supervise and ensure the effectiveness of the nursing interventions to prevent Resident #6 from falling.

Based on observations, interview with facility staff, review of medical records, and review of facility documents, it was determined that the facility failed to have a system in place to consistently prevent, identify, monitor and treat residents at high risk for altered skin integrity. This was evident for 2 (Resident #53, #17) of 39 residents reviewed during stage 2 of the Quality Indicator Survey (QIS) process. The findings include: The Prevention of Pressure Ulcers Policy was given to the surveyor by the Nursing Home Administrator on 2/3/16 and was reviewed the same day. Under General Preventive Measures, number 3a indicated that for a person in a chair, change position at least every hour. Also given to the surveyor was a Wound Care Policy. Under the Documentation section it stated the following should be done: type of wound care given, date and time, position in which the resident was placed, name and title of the individual performing the wound care, all assessment data (wound bed color, size, drainage, etc). Interview with the Director Of Nursing (DON) on 2/3/16 at 5:30 PM revealed that the staff member responsible for doing weekly skin checks was no longer employed at the facility for the past couple of weeks and that there was no longer one consistent staff member performing weekly skin checks. 1) Resident #53 was an [AGE] year old male with [MEDICAL CONDITION] and a history of pressure ulcers who was totally dependent on staff for all aspects of daily living (ADL) due to severe cognitive impairment. According to the 12/4/15 annual Minimum Data Set assessment, C0100, the resident was not interviewable according to B600 to B800. Further review of the MDS assessment, section G, Activities of Daily Living indicated the resident was totally dependent on staff for all ADLs and section H0300, Urinary Continence, indicated the resident was always incontinent of urine. The MDS (Minimum Data Set) forms the foundation of a complete assessment of the resident which provides the facility with the information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. During stage 1 of the QIS, review of the medical record on 2/2/16 at 9:05 AM documented a Stage 2 pressure ulcer on the coccyx measuring 1.0 cm by 0.7 cm by 0.1 cm on the wound evaluation form dated 1/12/16. Also documented was an open wound on the posterior left and right scrotum measuring 0.1cm by 0.5 cm by 0.1cm. From 1/12/16 through 2/2/16, there were no subsequent wound assessments by licensed staff found in the medical record to indicate if the open wounds were still present, if they had worsened, if they had healed, or if any new ulcers had developed. Further review of the medical record revealed active physician orders [REDACTED]. turn and position every 2 hours and prn every day and night shift. On 2/2/16 at 9:45 AM, while continuing the collection of resident data during stage 1 of the QIS, a staff interview was conducted with Licensed Practical Nurse (LPN) #1 (the nurse responsible for the resident). When asked if Resident #53 had any pressure ulcers, LPN #1 stated no. On 2/3/16, during stage 2 of the QIS, Resident #53 was observed on the third floor nursing unit sitting in a wheelchair with a lap buddy attached to the front of the wheelchair from 9:00 AM until 1:20 PM. A lap buddy is a restraint and is a thick flat cushion that fits over a person's lap and under the armrests of a wheelchair. At no time during that observation was the resident's position changed in the wheelchair, nor was the resident toileted. The resident was not put back to bed after breakfast as was ordered. At 1:20 PM, GNA#1 took the resident into the hall bathroom and brought the resident back out to the sitting room to watch television. At 2:50 PM, Resident #53 was observed in bed, which was 2 hours after eating lunch. On 2/3/16 at 3:00 PM, GNA #1 was asked what care was provided to Resident #53. GNA #1 stated he is total care. The surveyor asked what do you do about toileting and the response was change every 2 hours. The surveyor asked specifically what care was given when changing and GNA #1 indicated that they change brief, use washcloth, soap and water, dry and put a diaper back on. The surveyor then stated to GNA #1 tell me the care that you provided to the resident today. GNA #1 stated got him up between 6:30 and 7:00 and brought up front to get ready for breakfast. Then took into TV room. We try to change him before lunch. He just laid down about one half hour ago. He is a Hoyer lift so it takes 2 of us to put him to bed. He is on a specialty mattress and I elevate the head and feet - I do that with most people. The surveyor asked if there were any open areas on the resident's bottom and the response was no open areas as of right now. Oh maybe on his bottom he has a small open area and we put lotion on him. I don't think it was there when I wiped him this morning. On 2/03/16 at 3:05 PM, LPN #1 was asked to show the surveyor where the Treatment Administration Record (TAR) was signed off. LPN #1 showed the surveyor that everything was signed off in the TAR which was kept in the Electronic Medical Record (EMR). The TAR documentation for the shift indicated that Resident #53 had been turned and repositioned every 2 hours, laid down in between meals, his heels had been floated when in bed, buttocks, coccyx and scrotum were cleaned with soap and water, calmaseptine lotion was applied to coccyx and scrotum, and incontinence care was provided every 2 hours. LPN #1 was then asked about subsequent skin assessments for the documented pressure ulcer of 1/12/16. LPN #1 said she was unaware and was unable to find anything in the medical record. LPN #1 was also not able to describe or explain any facility system for managing wound care treatments. LPN #1 asked another nurse on the unit who would know about pressure ulcers and LPN #1 was directed to ask another nurse on the second floor unit. The surveyor accompanied LPN #1 to the second floor. Registered Nurse (RN) #1 was asked by LPN #1 if RN #1 was doing wound rounds. RN #1 stated that she had just printed off what needed to be looked at per the TAR. RN #1 stated that if there were any skin sheets LPN #1 would have to go ask the Director of Nursing (DON.) At that point the surveyor advised LPN #1 that the surveyor would go find the DON and ask about further skin assessments in which LPN #1 stated ok. On 2/3/16 at 3:30 PM, the DON could not find any documentation in the medical record for Resident #53 related to status of pressure ulcer. On 2/3/16 at 3:40 PM, the surveyor and the DON went to go observe Resident #53. The DON removed the top sheet that was covering Resident #53 and observation was made of both heels lying directly on the bottom sheet of the mattress. There was bilateral pedal [MEDICAL CONDITION]. The heels were not floated as indicated by the initials of LPN #1 on the TAR. The DON proceeded to get a blanket/comforter out of the closet to float Resident #53's heels. On 2/3/16 at 4:30 PM, the surveyor requested that Resident #53 have a skin assessment done by licensed staff. At 5:10 PM, the surveyor requested to be notified of the result of the skin assessment. The surveyor was advised that there were 3 wounds (the sacral wound remained, the two scrotal wounds resolved, and 2 new wounds had developed but had not been identified or treated.) On the sacrum was an unstageable pressure ulcer measuring 1 cm by 1 cm by 3 cm. By 2/2/16, there was also a pressure ulcer on the left inner buttock near the rectum measuring 0.2 cm by 0.1 cm by 0 cm and another on the right inner buttock near the sacrum measuring 0.3 cm by 0.4 cm by 0.1 cm. There were no open areas on the scrotum. Review of the record also revealed that, as of 2/3/16 at 3:23 PM, GNA #1 had signed off on the Kardex of Resident #53 that there were no open areas. 2) A second resident, Resident #17, an [AGE] year old female with [MEDICAL CONDITION] and a history of pressure ulcers was also included in the Stage 1 resident sample. During the staff interview on 2/2/16 at 9:55 AM, the surveyor was advised that the resident did not have a pressure ulcer. Resident #17, who was also totally dependent on staff for all aspects of daily living due to severe cognitive impairment and incontinence of bladder according to the quarterly MDS assessment with an ARD of 10/28/15, was observed on the third floor nursing unit. On 2/3/16 from 9:00 AM to 1:52 PM, Resident #17 was observed sitting/lying in a reclining position in a reclining geriatric chair. The resident was not observed to be turned and repositioned during the nearly 4 hour observation period. The resident was observed being wheeled out of the activity room and directly to the dining room after the activity had concluded and then to the hallway adjacent to the nursing station. The resident was not taken to have incontinence care done until the resident was put back to bed at 1:52 PM. Review of Resident #17's medical record revealed a history of a pressure ulcer to the left isheal tuberos (near the sitting bones) which was documented as closed in a 1/13/16 wound evaluation. Review of the February 2016 TAR documented that the resident was turned and reposition every 2 hours and heels were floated while in bed for pressure relief. On 2/3/16 at 3:45 PM, the surveyor and the DON went to observe Resident #17. The surveyor requested the DON to check to see if Resident #17's heels were floated as signed off by LPN #2. The DON pulled back the top sheet which revealed the residents heels were not floated as the heels were directly on the mattress. The DON had to locate an item in the room to float Resident #17's heels. On 2/3/16 at 5:20 PM, surveyors requested that Resident #17 have a skin assessment done by licensed staff. At 5:30 PM, the DON, RN #2 and 2 RN state surveyors observed the skin of Resident #17 which revealed an open area on the coccyx measuring 1.5 cm by 1.2 cm by 0.2 cm. According to GNA documentation on Resident #17's Kardex, there were no open areas as of 2/3/16 at 3:41 PM. The failure of the facility to ensure that nursing staff were fully aware of the needs of residents in their care, and the system failure to provide and document care consistent with facility policies, consistent with standards of practice, consistent with care plans, consistent with orders, and consistent with basic resident needs, resulted in harm to Resident #53 and #17 and placed many residents at increased risk for serious preventable pressure ulcers. As a result a condition of Immediate Jeopardy was declared on 2/3/16 at 7:04 PM. The Nursing Home Administrator was informed of the need to prepare and implement an action plan to remove the condition of Immediate Jeopardy. The plan of correction was given to the surveyors on 2/3/16 at 9:00 PM. The plan that was immediately put into place, was a skin sweep of the entire facility population to determine if any other resident had altered skin integrity and any resident that was identified to be at risk would have an updated Braden Risk Tool completed. All current treatments were to be reviewed to ensure the treatments matched current orders. Review of the Resident Census and Conditions of Residents, CMS-672 Form, that was completed by the DON on 2/2/16 and given to the survey team indicated that there were 3 pressure ulcers in the facility out of the 74 current residents. After the skin sweep was done, there were 9 additional residents that were found to have altered skin integrity. The plan of correction to remove the immediacy (element of Immediate Jeopardy) was accepted and the Immediate Jeopardy was abated at 9:22 PM on 2/3/16.

Based on review of medical records, facility policy and interview with facility staff, it was determined that the facility failed to have a system in place to readily and accurately determine a resident's CPR (Cardio [MEDICAL CONDITION] Resuscitation) status. This was evident for 6 of 57 records reviewed for CPR status.The findings include: 1) Resident #85 was readmitted to the facility from an acute care hospital with a [DIAGNOSES REDACTED]. On [DATE] at 2:21 PM, Nurse #1 was asked what the stickers meant on the outside of the medical charts and she stated "orange for DNR" (do not resuscitate). Nurse #2 was asked at 2:31 PM what resident #85's code status (CPR) was, and she said "probably a full code because she doesn't have an orange sticker. " She then pulled the chart and looked at the face sheet (demographics about resident) and was unable to find the code status. Nurse #2 then asked Nurse #1 if she could find the status on the face sheetl, and Nurse #1 stated "I couldn't find it on the other chart either when I looked". Nurse #2 then stated "I would be coding her until someone tells me not, to because the MOLST (Maryland Medical Orders for Life Sustaining Treatment) form is not in the front of the chart. I always look at the MOLST first and then the face sheet. The corporate nurse came up and stated " it would be in point, click, care" (which is the computer program). The surveyor stated " what if the resident was here in the hallway on the floor without a pulse and not breathing and the corporate nurse stated, while she was looking in the paper copy of the chart, "she is 72 so I would imagine she is a full code. Should be on physician's orders [REDACTED]." The surveyor then stated " it took 4 minutes to figure out what the code status was." The physician's orders [REDACTED]. The MOLST order in the computer dated [DATE] was DNR, Option A-2. There was not a copy of the MOLST in the paper chart which was at the nurses station. The care plan dated [DATE] stated " FULL CODE " . In the state of Maryland, a MOLST form is a physician's orders [REDACTED]. The MOLST form is recognized throughout all of Maryland's healthcare systems. A resident is admitted to the facility with a completed MOLST form, or a MOLST form is completed by the facility when the resident's wishes become known. 2) Review of the record on [DATE] at 4:30PM revealed that resident #42's [DIAGNOSES REDACTED]. She experienced a significant weight loss of 29% over 180 days. The resident had a stage 2 pressure ulcer on her right ankle. She had a PICC (peripherally inserted central catheter) line - a type of intravenous line, to maintain adequate hydration. A social services progress note dated [DATE] revealed that the resident's son, who is her Power of Attorney, was in to change the resident's code status to "No Code with limited medical interventions". A physician's orders [REDACTED]. The resident's MOLST form dated [DATE] indicated to perform CPR. The resident's care plan, dated [DATE], stated "family wishes for resident to be a full code". 3) Review of resident #95's record on [DATE] at 3:35 PM revealed [DIAGNOSES REDACTED]. His physicians order, dated [DATE], indicated that he was a full code. Resident # 95's plan of care dated [DATE] also indicated that the resident wished to be a full code. His MOLST form dated [DATE] indicated No CPR, Option B. 4) Resident #47 [DIAGNOSES REDACTED]. Interview of Nurse #2 on [DATE] at 3:55 PM revealed that the resident was a DNR. Review of the resident's MOLST form, dated [DATE], indicated that he is "No CPR, option B". The resident's current active physician's orders [REDACTED]. There is also a nursing care plan dated [DATE] for Full Code, and a social work note of [DATE] stating that the resident is a full code. Interview of the Acting Director of Nursing on [DATE] at 4:55 PM revealed that the facility staff is trained to use the physician's orders [REDACTED]. According to the ADON, the facility is not using the orange dots located on the spine of some of the hard copy medical records. A copy of the Advance Directives policy was provided, which had been revised [DATE]. Number 9 of the policy stated that the physician will be notified so that appropriate orders can be documented in the resident's medical record and plan of care. 5) Resident #111's [DIAGNOSES REDACTED]. Her MOLST form, dated [DATE], indicated her code status is a "No CPR, Option A-2". Her current active physician orders [REDACTED]. 6) Review of resident #115's medical record, on [DATE], revealed a physician order, dated [DATE] indicating that the resident's code status is a "DNR-B". Review of resident #115's MOLST form, dated [DATE], indicated that resident #115 wanted to be a "No CPR". Review of resident #115's medical record information sheet dated [DATE] indicated that resident is a "Full Code". Observation of resident #115's medical record exterior binder failed to reveal a facility sticker indicating that resident #115 was a DNR. The facility staff failed to update resident #115's information sheet indicating that resident's code status was DNR, which potentially could have lead to the facility staff performing CPR and not following resident #115's wishes to be a DNR. In summary, in 6 out of 57 charts, the resident's code status was documented differently within the same medical record, and multiple facility staff looked in a variety of locations in the chart to determine a resident's code status. The facility failed to have a process in place to readily and accurately determine a resident's CPR status. In the event of an emergency, residents who have limitations on cardiopulmonary resuscitation are at risk for receiving interventions against their wishes. As a result, a condition of Immediate Jeopardy was declared on [DATE] at 10:30 PM and was abated on [DATE] at 2:25 AM when an acceptable plan of correction was implemented.