Deficiency Text Not Available

Based on record review and interview it was determined the facility failed to ensure a thorough investigation was performed for an injury of unknown origin. This was evident during the surveyor's review of facility reported incident #MD00200761 reviewed by the surveyor during the facility's recertification/complaint survey. The findings include: On 12/6/24 at 8:22AM the surveyor requested the complete investigation file for facility self-report #MD00200761 from the facility's Administrator. On 12/6/24 at 8:42AM the surveyor received the investigative file from the Administrator who confirmed this was the complete investigation file. Review of the facility's initial self-report revealed Resident #220's hip fracture was reported as an injury of unknown source to the Office of Health Care Quality on 12/19/23 at 10:30AM. Review of the follow up self-report revealed the following information was documented: Resident had a fall on 11/28/23 from his/her wheelchair. On 12/10/24 at 9:58AM the surveyor conducted a review of the medical record of Resident #220 which revealed the following was documented in a nursing progress note dated 11/28/23 at 2:01PM: At 11:30AM nurse was called to resident's room, observed resident laying face down in front of w/c (wheelchair), Resident slid out of w/c, sustained hematoma to left side of forehead size of a golf ball, ice applied, Root cause determine from constant agitation, always reaching and trying to grab things around him/her, Frequent yelling at all times on going behavior, Neuro check initiated WNL (within normal limits), on routine pain management . On 12/10/24 at 10:53AM the surveyor conducted an interview with the facility Administrator who reported the following information to surveyors regarding the root cause analysis process for Resident #220: We think through what could be done for this resident, s/he can't communicate, does s/he need a new cushion, did s/he slide out of it because of the traction? At this time, the surveyor provided opportunity to the Administrator for all documentation and actions taken by the facility regarding Resident #220's 11/28/23 incident to be provided to the surveyor for review. During the interview, the Administrator reported to the surveyor that the risk meeting documentation that had been provided to the surveyor was the risk meeting minutes and there was no other documentation for the risk meetings. On 12/10/24 at 11:50AM the surveyor conducted another interview with the facility's Administrator who reported to surveyors the following information regarding the 11/28/23 incident for Resident #220: S/he slid out of his/her wheelchair, s/he was in a room by her/himself, Staff do rounds every two hours typically, a lot of staff walk by, someone was walking by and from the note s/he was found there on the floor. When the surveyor inquired as to if there was an investigation performed and an investigation file for the 11/28/23 incident, the Administrator replied: No, we don't keep investigation files for every single fall, we don't report every single fall to your office, it's only when they have injuries, it was part of the (12/19/23) investigation because we said the (12/19/23) fracture was related to the (11/28/23) fall. At this time the surveyor inquired as to how staff ruled out abuse and neglect and how staff knew that Resident #220's hematoma was from a fall sliding from the wheelchair; to which they replied: because s/he was on the floor. At this time, the surveyor shared their concerns and noted that the 11/28/23 incident resulting in an injury of unknown origin with the resident having been documented as sustaining a hematoma to the left side of their forehead the size of a golf ball in which neuro checks were instituted, was not reported to the Office of Health Care Quality. There was no investigation file that could be provided to the surveyor for the 11/28/23 incident. Review by the surveyor on 12/10/24 at 11:53AM of the facility's incident report dated 11/28/23 documented the following was selected on the report: alleged fall, unattended. Other options present on the incident report were: abuse investigation for unknown injury, and abuse ruled out, in which neither of these options were observed selected. On 12/10/24 at 12:53PM the surveyor reviewed the root cause analysis for the 11/28/23 incident which was risk meeting documentation that consisted of the following: On 11/28/23 before lunch resident was found on the floor in front of his/her bed, Resident slid off his/her wheelchair, Offer to lay down after breakfast, New cushion in place by rehab team. The surveyor noted that there was no documentation of a thorough investigation to support how the interdisciplinary team came to those conclusions.

Based on interview with residents, review of resident medical records, and interview with facility staff, it was determined that the facility failed to hold care plan meetings at least quarterly. This was evident for 1 (Resident #17) of 1 resident reviewed for care planning during the recertification/complaint survey. The findings include: On 12/03/24 at 03:02 PM, Resident #17 was interviewed. During the interview, the resident indicated that s/he did not recall ever being invited to a care plan meeting but would like to attend one. On 12/12/24 at 10:34 AM, Resident #17's medical record was reviewed. The review revealed that the resident was admitted to the facility in June, 2024. The review failed to reveal evidence that a care plan meeting was held after the initial care plan meeting in June. On 12/12/24 at 11:16 AM, the Health Center Social Worker (SW) #9 was interviewed. During the interview, SW #9 indicated that residents should receive a care plan meeting on admission and quarterly. She stated that she creates a sign-in sheet for the meeting, a letter inviting the resident's responsible party (or the resident themselves) to the meeting, and documents a summary of the meeting. All of these documents should be stored in the electronic health record. When asked for evidence of Resident #17's most recent quarterly care plan meeting, SW #9 could only find a letter inviting family to the initial care plan meeting in June. After looking in the resident's paper medical record, current and previous electronic medical record, and in her personal computer files, she found no evidence that a care plan meeting occurred since June for Resident #17. She stated, [the resident] should have had one in September. I missed that.

Based on observation during medication administration it was determined that the facility failed to follow infection control practices consistent with accepted standards of practice. This was evident for 3 (Residents #5, #10 and #13) of 4 residents reviewed for medication administration during the recertification/complaint survey. The findings include: On 12/06/24 at 8:17AM, surveyors observed LPN #10 drop Resident #5's medication bottle on the floor in the hallway on Cedar Place. LPN #10 picked up the medication bottle for Resident #5 off the floor and placed the medication bottle back in Resident #5's medicine drawer in the medication cart without sanitizing the medicine bottle or their hands. On 12/06/24 at 8:35AM, surveyor observed LPN #10 give Resident #5 their medications and leave Resident #5's room without sanitizing their hands. LPN #10 then retrieved the Blood Pressure (BP) cuff from the hallway on Cedar Place and entered Resident #13's room and took Resident #13's blood pressure. On 12/06/24 at 9:19AM, LPN #10 went to get another computer because the computer on the medication cart no longer worked. LPN #10 returned and hooked up a different computer on the medication cart. LPN #10 did not sanitize their hands and picked up the water pitcher, poured water in a clear plastic cup and went into resident #10's room and gave Resident #10 their medications. On 12/06/24 at 10:12AM, on Cedar Place during medication administration, surveyor observed two syringes sitting in the top part of the sharps container attached to the side of the medication cart. The two syringes appeared to be used and were accessible due to staff not pulling the lever on the side of the sharps container to discard the syringes in the bottom of the sharps container where they cannot be retrieved.

Based on observation and interview it was determined the facility failed to ensure privacy of protected health information was maintained for residents of the facility (#8, #16, #12, #122, #2, #3, #11, #14, #7, #1, #17). This was evident for 11 out of 21 residents during the facility's recertification/complaint survey. The findings include: On 12/11/24 at 3:13 PM surveyors observed an unlocked, unattended monitor screen in the resident hallway which displayed the photo images of 11 residents of the facility (#8, #16, #12, #122, #2, #3, #11, #14, #7, #1, and #17) with their medical record numbers listed next to their photo images. The monitor screen also displayed various tabs and applications. Geriatric Nursing Assistant (GNA) #12's name was observed on the screen. On 12/11/24 at 3:17 PM surveyors observed GNA #12 enter the resident hallway at which time surveyors shared their concerns and conducted an interview. GNA #12 observed the concern and stated the following during the interview: Okay, let me close it. On 12/11/24 at 3:18 PM surveyors requested a dual observation of the concern with the facility's Director of Nursing (DON) #8 and shared the concern. The DON observed the concern and acknowledged and confirmed understanding of the concern and was observed stating the following information to GNA #12: You can't leave it unlocked. At this time, the DON was observed locking the monitor screen for GNA #12. On 12/13/24 at 9:47 AM the surveyor shared all concerns with the facility's Executive Director who acknowledged and confirmed understanding of the concerns. On 12/13/24 at approximately 3:45 PM the concern was again shared during the facility's exit conference with surveyors.

Based on observations, interviews and facility record review it was determined the facility failed to ensure food handling practices were followed in accordance with professional standards for food service safety, ensure the dishwashing system met the required minimum temperatures and chemical concentration, ensure monitoring of dishwasher chemical concentration and food service equipment functioning, ensure thorough environmental cleaning of the kitchen, and ensure the monitoring of food temperatures and food storage. These deficient practices have the potential to affect all residents. The findings include: On 12/2/24 at 8:00AM during the surveyor's initial tour of the facility's kitchen the surveyor noted the following signage was present: Attention team! All food items must have the following: label, date, item covered. On 12/2/24 at 8:03AM during the surveyor's initial tour of the facility's kitchen the surveyor noted the following signage present on the facility's walk-in refrigerators/freezers: All product stored in this walk-in must be: covered, labeled, dated, any product over five (5) days old must be discarded. On 12/2/24 at 8:04AM the surveyor observed baking trays on a movable rack within the walk-in freezer containing the following items: an open, spilled bag of frozen corn mix on a baking tray, scattered pieces of ginger, a package containing two squares of brown meat-type product in which the label read: If frozen, best by 10JAN2023 which was noted to have lost the vacuum type seal, an unlabeled brown meat product loosely wrapped in saran wrap with uncovered areas exposed, unlabeled white meat product in a bag, an open unlabeled bag of cream puffs, an opened unlabeled bag of biscuit/cookie type dough, a package of brown meat with a label which read 10/7/24 and did not identify what the product was, assorted, spilled, uncovered pieces of foods/crumbs, a pan of prepared meat with a label which read 11/28 and did not identify what the product was, an open bag of turnover pastries with uncovered areas, an unlabeled bag of meat type product, a pan of prepared food with a label which read: 10/24 and no information identifying what the food was, a pan of what appeared to be chicken with a label which read: 11/28 with no identifying information as to what the food product was, an open and exposed package of pie crusts, 2 pans of frozen meat with no labeling, a package of open and spilled okra, and another pan of meat-type product with a label which read: 5/7 with no information indicating what the food was. Concerns were shared with [NAME] #5 who observed the concerns and reported they did not know when the foods should be thrown away, and was unable to identify what many of the food items were. On 12/2/24 at 8:10AM the surveyor observed 8 metal pans containing food products in the walk-in refrigerator with a label indicating a prep date of 12/1 with no information identifying the food products. One container of raw meat was observed stored next to a container of ready to eat salad. A bag of saran wrapped chopped cooked meat-type product was observed with a label dated 11/24, however there was no indication on the labeling of what the product was. Another bag of meat type product was observed dated 11/24 with no other identifying information completed on the labeling. Concerns were shared with [NAME] #5 who acknowledged and confirmed understanding of the concerns. On 12/2/24 at 8:11AM the surveyor observed a pan of roast beef slices in the walk in refrigerator with a label which read: 10/30. [NAME] #5 confirmed with the surveyor that this should have been discarded. On 12/2/24 at 8:12AM the surveyor observed a container of labeled teriyaki sauce in the walk in refrigerator with a date of 11/24. [NAME] #5 confirmed with the surveyor that this should have been discarded. On 12/2/24 at 8:12AM the surveyor observed a meat-type mixture in a pan in the walk in refrigerator that had a label dated 11/21. The label did not identify what the food product was. [NAME] #5 confirmed with the surveyor that this should have been discarded and removed the item from the refrigerator. Observation by the surveyor on 12/2/24 at 8:13AM of the walk-in refrigerator near the kitchen's office revealed a saran wrapped tray which included cheese, strawberries, and grapes on it with a label dated 11/19. [NAME] matter/growth and brown areas was observed on strawberries. The circular thermometer located on the outside of the walk in refrigerator was observed to have masking tape on it, and was covered with frost on the inside. Observation of the temperature on the exterior thermometer of the walk in refrigerator read approximately -20 degrees, as compared to the surveyor's observation of the interior thermometer which read approximately 41 degrees. Foods within the walk-in refrigerator were noted to be refrigerated, not in frozen condition, indicating the exterior temperature gauge was not properly functioning. Concerns were shared with [NAME] #5 who observed the concerns, and removed the fruit and cheese tray. On 12/2/24 at 8:17AM the surveyor observed an unlabeled baking tray in the reach-in refrigerator which contained 6 slices of pie and one brownie dessert. Further observation of the reach-in refrigerator revealed a tray of cherry jello dated 11/14. On 12/2/24 at 8:21AM the surveyor observed the ice cream refrigerator chest and requested from [NAME] #5 to review the temperature log, at which time they reported to the surveyor that there was not a temperature log for it. On 12/2/24 at 8:22AM the surveyor observed the facility's conveyor dishwasher and noted that the circular wash and rinse temperature gauges appeared inoperable and had cracks present on both clear covers. The surveyor observed that the dishwashing machine was marked with signage indicating the following: Notice: This machine is currently in hot water sanitizing mode. Thick white matter was observed to be present on a plumbing piece which connected to the dishwasher chemical lines. On 12/2/24 at 8:24AM the surveyor observed a plastic container with broken edges and corners on it's lid located in the walk-in refrigerator which held chopped greens. A pan of cream based orange colored mixture was observed to have a label dated 11/27 with no other identifying information present. On 12/2/24 at 8:25AM an uncovered opening was observed to be present on a carton of mustard potato salad in the walk-in produce refrigerator which had no labeling present indicating a date or time of opening. On 12/2/24 at 8:26AM the surveyor observed mixed cut fruit in an unlabeled plastic container with broken corners of the lid where the fruit was observed to be uncovered. On 12/2/24 at 8:27AM the surveyor requested to [NAME] #5 to review food internal cooking temperature logs, to which they responded: I haven't seen it, we have to get temp logs and start recording temperatures. [NAME] #5 further reported to the surveyor that the facility does not keep any documentation of food temperatures taken during the cooking process. [NAME] #5 referred the surveyor to the skilled nursing unit where temperature logs were kept when taken on the steam table. On 12/2/24 at 8:30AM the surveyor observed the contents of a smaller refrigerator located near the food preparation and cooking areas. A plastic pan with a label dated 8/6 was observed within the refrigerator containing several individually packaged portion size packages of thawed pureed chicken, and condiment containers of cranberry orange sauce. 6 out of 13 cranberry orange sauce condiments were observed by the surveyor to have a green, fuzzy material present on them. An additional container of mint jelly was observed to be dated 11/14. An opened, saran wrapped package of pita bread was observed to be labeled 9/29. A saran wrapped container of red sauce was present with a label present with no identifying information of what the sauce was. [NAME] #5 reported this was strawberry glaze. A pan labeled with a date of 11/12 was observed containing individual cups of cole slaw. An unlabeled disposable soup container with mashed potatoes in it was observed within the fridge. A dual observation of the concerns was conducted with [NAME] #5 who acknowledged and confirmed understanding of the concerns. On 12/2/24 at 8:37AM the surveyor observed a metal pan of cookies with a label which read: 11/26. Upon further observation of the container, the surveyor observed flies through the saran wrap, flying around within it. The surveyor conducted a dual observation of the concern with [NAME] #5 who acknowledged observation of the flies, and confirmed understanding of the concern. The surveyor observed them pick up the pan and move it to a food preparation table. When the surveyor further inquired as to what [NAME] #5 would do with the pan, they stated to the surveyor that they were leaving the flies in the container in order to show their supervisor the concern and would be discarding the cookies, and ensured they would not be served. On 12/2/24 at 9:17AM the surveyor conducted an interview with Dietary Aide #13 who stated the following information regarding food temperatures in the skilled nursing unit food serving area: I microwave it if it's not up to temperature, then we see and check again. On 12/2/24 at 9:20AM the surveyor observed the skilled nursing unit food serving area and requested to review the food temperature logs. The surveyor reviewed the logs and observed there was no documentation of any food temperatures taken for the dinner meal on 12/1/24. The following items were recorded for the dinner meal without any temperatures documented: crab cake, vegetable lasagna, salmon, fish chowder, mashed potato, sweet potato, peas, corn, and spinach. On 12/2/24 at 9:24AM the surveyor conducted an interview with Dining Services Director (DSD) #2 who confirmed with the surveyor that there was no internal food temperature log. When the surveyor inquired as to if a temperature log should be in place for this, they stated: Sure it should be. The surveyor conducted a dual observation of the food temperature log for the 12/1/24 dinner meal with DSD #2 and shared the concern with DSD #2, who acknowledged the concern. The surveyor shared all concerns with DSD #2 who stated the following to the surveyor: Oh yeah, so do I, We threw a bunch of stuff out. DSD #2 confirmed they were able to visualize concerns the surveyor had, and acknowledged and confirmed understanding of the concerns. The surveyor made a request to DSD #2 for a copy of the 12/1/24 dinner temperature log. On 12/2/24 at 9:25AM the surveyor conducted an interview with Certified Dietary Manager (CDM) #3 who reported the following information to the surveyor: Temperatures should be taken at the start and at the end; the raw and finished product. CDM #3 confirmed with the surveyor that cooking of the food occurs in the facility's kitchen and when the food goes upstairs, we temp it before it goes in the steam table. On 12/5/24 at 11:12AM the surveyor observed the reach-in refrigerator temperature log was completed and filled out prior to lunchtime for the lunch and closing time temperatures for 12/5/24, and the open, lunchtime, and closing temperatures recorded, were documented as 51F for all three temperatures. The surveyor noted that 51F did not meet the minimum requirement of 41F or below for refrigerator temperatures, and the reach-in refrigerator was holding items which included: milk, sour cream, butter, caesar salad and other salads, pumpkin, and fruit. Observation of the food in the reach-in refrigerator revealed that labels present on foods now included identifying information of what the foods were. The surveyor shared concerns with CDM #3, and inquired as to if the elevated reach-in refrigerator temperatures on the log had been brought to their attention. CDM #3 confirmed they were not aware of any elevated temperatures and reported to the surveyor that no staff had notified them of any issues with the temperature of the refrigerator. On 12/5/24 at 11:23AM the surveyor was approached by CDM #3 who reported to the surveyor that gaskets had been replaced on the reach-in refrigerator in the summertime, and they had a vendor coming to check on it again, because when you shut the door, the other one opens, and we are constantly, shut, shut, shutting it. On 12/5/24 at 11:25AM CDM #3 showed the surveyor the issue occurring with the double doors to the reach-in refrigerator. The surveyor observed that when the door on the left shut, the door on the right popped open and was no longer closed. On 12/5/24 at 11:27AM surveyors observed thick grey matter on approximately 7 cords located on/above the food prep area near the cooking area. On 12/5/24 at 11:30AM the surveyor conducted a dual observation of the thick grey matter and shared concerns with CDM #3 who observed the concern and stated the following: We'll get it taken care of. CDM #3 acknowledged and confirmed understanding of the concerns. On 12/5/24 at 11:31AM CDM #3 was observed directing Dishwashing Staff #7 to cover the food area and and clean the dust. On 12/5/24 at 11:35AM the surveyor observed the reach-in refrigerator temperature log now had white out present on it, and an opening temperature of 37 degrees was now written over the white out. On 12/5/24 at 11:52AM the surveyor observed that dishes were in a metal pan on the steam table with a cloth over them for warming of the plates. When the surveyor inquired as to why the plate warming system present was not being used, Health Center Supervisor #14 stated the following to the surveyor: We have always done it this way, it has been broke for a long time. CDM #3 was observed flipping the switch to the plate warming system which revealed there was no indicator light turning on, and the system did not begin to heat. On 12/5/24 at 1:12PM the surveyor shared concerns with the facility's Administrator, who acknowledged and confirmed understanding of the concerns. On 12/6/24 at 8:21AM the surveyor requested from the facility Administrator to be provided with all policies and procedures relating to the kitchen. On 12/6/24 at 10:10AM the surveyor observed the items previously identified on 12/2/24 at 8:05AM continued to be present in the freezer. The surveyor additionally observed several trays of pies were present in the freezer which were partially uncovered. On 12/6/24 at 10:17AM the surveyor observed the dishwasher monitor to be red in color with a triangle and exclamation point symbol present on it. The temperature for the wash was observed to be reading 94.1F, and the temperature for the rinse was observed to be reading 116.2F on the monitor. Continued observation by the surveyor of dishes being put through the dishwashing system on 12/6/24 at 10:18AM revealed a wash temperature of 94.1F and a rinse temperature of 127.6F on the monitor. The following was observed on the monitor: Low rinse temperature. Continued observation of the circular temperature gauges for rinse and wash revealed the needles were barely moving throughout the dishwashing process, indicating they were not properly functioning. On 12/6/24 at 10:19AM the surveyor observed the dishwasher was connected to a container of liquid chemical, indicating that the dishwasher was being utilized in chemical sanitizing mode for sanitization. Review of the manufacturer plackard located on the machine indicated the following requirements for chemical sanitizing: minimum wash tank temperature 140F, minimum final rinse temperature 120F, minimum chlorine required 50ppm. The surveyor noted that signage present on the machine indicated the machine was in hot water sanitizing mode although the machine was currently operating in chemical sanitizing mode. On 12/6/24 at 10:26AM the surveyor reviewed dishwasher temperature logs which revealed consistent documentation that the minimum required temperatures were not reached. Review of the facility's food receiving and storage policy revealed the following information in the policy: Food services, or other designated staff, will maintain clean food storage areas at all times, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date), Such foods will be rotated using a first in first out system, Uncooked and raw animal products and fish will be stored separately in drip proof containers and below fruits vegetables and other ready-to-eat foods. On 12/6/24 at 10:30AM the surveyor conducted an interview with CDM #3 who stated to the surveyor that the dishwasher's booster heater (a type of water heater which heats water to the proper temperature for sanitizing dishes in a dishwasher) had failed earlier in the year and the UltraSan chemical was now being used. On 12/6/24 at 11:27AM the surveyor conducted an interview with DSD #2 who reported to the surveyor that the liquid chemical for dish washing was ppm (parts per million) tested (for adequate levels of chemical concentration needed for effective sanitization) every other week by their vendor. When the surveyor inquired as to what range the chemical concentration should result at, they reported that they did not know. On 12/6/24 at 11:42AM the surveyor conducted an interview with contact information provided by the facility for vendor technician #15 who reviewed the facility's vendor records and reported to the surveyor that 11/11/24 was the last time the vendor's assigned technician had visited the facility, and there was no documentation of the ppm test result in their report for that visit. Vendor technician #15 advised the surveyor that there were no future appointments presently scheduled with the facility, and that in addition to technicians checking the ppm at service calls, facility staff are recommended to be checking the ppm every day, every shift, and the circular temperature dials should be working in addition to the monitor. Vendor technician #15 confirmed with the surveyor that if the minimum water temperatures for the machine were not met for the wash cycle, the machine is not able to effectively clean grease and heavy soil prior to the rinse cycle which then utilized the chemical sanitizer. On 12/6/24 at 1:25PM multiple surveyors observed the dish washing system in operation as dishes were being put through the machine. The wash temperature was observed at 100F for the wash, and 117F for the rinse on the monitor, which were both below the minimum temperatures located on the machine's plackard for chemical sanitization. On 12/6/24 at 1:34PM surveyors observed the circular temperature gauges on the dish washing machine while in operation and noted that the left sided gauge needle was barely moving and read 109F, and the right sided gauge needle was not moving and read 114F. When the surveyor inquired as to the condition of the circular gauges, DSD #2 stated: It's calibrated through (vendor) we have no way of checking that, honestly, I don't know. When surveyors inquired as to where the ppm testing log was kept, CDM #3 informed surveyors that there was no log. When surveyors inquired as to how the ppm testing of the chemical concentration was tested, DSD #2 stated the test strips were in their office. DSD #2 retrieved test strips from their office, and returned with Hydrion QT-40 test paper which was observed being put through the dish machine, and the test paper did not return at the end of the dishwashing process. Surveyors observed Chef #16 wrap another piece of the test paper around a fork, and send it through the machine, which returned with no color change having resulted. Chef #16 then obtained a different container of test strips that were labeled for chlorine testing and wrapped it around a fork and sent it through the dishwasher, which revealed a pale yellow test result which did not closely match any of the color indicator test results on the guide on the test strip bottle. On 12/6/24 at 2:03PM the surveyor conducted an interview by phone with Vendor Technician #15 who reported to the surveyor that a chlorine strip should be used for ppm testing and should have a result of 50-100ppm, indicating appropriate chemical concentration levels. Vendor Technician #15 further advised that the test strip should be testing the water that is present after dishes are put through the dish washing system. On 12/6/24 at 2:17PM the surveyor observed Chef #16 dipping a test strip into the water pan within the machine, and no color change was noted to the strip. When the surveyor asked the procedure to be performed according to the vendors recommendation, the test strip color was observed to change, and when compared to the test strip bottle color indicators, was resulting at 25ppm, which was below the recommended concentration level for chemical sanitization. The 25ppm test result was acknowledged and confirmed by DSD #2, Chef #16, and multiple surveyors. On 12/6/24 at 3:13PM the surveyor conducted an interview with the facility Administrator. When the surveyor inquired as to when they had assumed the role of Administrator they stated: I'm going to get back to you on that. When the surveyor inquired to the Administrator if they were aware of issues concerning the dishwasher, they stated: I heard about it today from DSD #2, the p level was barely off with the sanitization, the color was slightly off, just the booster was not working, that's why they have the sanitization, but that's it, I'm not sure, I would have to get back to you. The surveyor shared all concerns with the Administrator and informed them that 25ppm was 25ppm below the minimum of the range for the ppm chemical concentration for effective sanitization. The Administrator acknowledged and confirmed understanding of the surveyor's concerns. On 12/9/24 at 11:10AM the surveyor observed the skilled nursing unit nutrition refrigerator located in the dining room which revealed one thermometer was present, and was observed to be in broken condition. The area on the inside of the thermometer where the result is read was in a diagonal position and read 46F, which did not meet the minimum required temperature. The surveyor reviewed the temperature log for the refrigerator which had last been recorded as 40F at opening for 12/9/24. At this time, the surveyor noted the temperature log for 12/8/24 was incomplete with no closing temperature recorded on the refrigerator or freezer logs. On 12/9/24 at 11:11AM the surveyor observed the skilled nursing unit nutrition freezer located in the dining room which contained an unlabeled disposable beverage cup with white contents, and a damaged container of lactaid ice cream with the contents visible. Further observation of the skilled nursing unit refrigerator on 12/9/24 at 11:11AM revealed a plastic bin of thawed magic cups and a plastic bin of strawberry shakes with no labeling present. When the surveyor inquired to Dietary Aide #13 as to when the products would be discarded, they confirmed the products should be dated, and responded: I will date and time them from now on, and only put 5 or 6 in there at a time, I don't know when these trays were put into the refrigerator. On 12/9/24 at 11:15AM the surveyor requested and performed a dual observation of the concerns with the facility Administrator. Dietary Aide #13 reported to the Administrator that no dates were put on the plastic containers. On 12/19/24 at 11:20AM the surveyor observed the Administrator throw away the cup from the freezer and stated: that's gross. When the surveyor inquired as to what further action would be taken, the Administrator reported the magic cups would be thrown away and a thermometer was observed being removed from the freezer and placed into the refrigerator. When the surveyor inquired as to if any other action would be taken, they stated: We will review the food that is in there and wait until it recalibrates, and we will see how accurate that temperature gauge is with the new one. The surveyor noted that it could not be ensured that the refrigerator had maintained minimum required temperatures for the food items it contained. On 12/9/24 at 11:43AM multiple surveyors observed the thermometer within the skilled nursing unit refrigerator which read: 50F. On 12/9/24 at 11:45AM the surveyor was informed by Dietary Aide #13 that DSD #2 was ordering a new refrigerator. On 12/9/24 at 3:07PM the surveyor conducted an interview with the facility's Executive Director who reported the following to surveyors regarding kitchen concerns: I was made aware on Friday, no I have not been made aware of any issues, not since I have been here February of 2023. They confirmed with the suveyor that if equipment fails, they would be expect to be notified, but if equipment was malfunctioning, that information would be provided to the DSD. The Executive Director further reported the following to surveyors: Staff would only come to us if they weren't able to resolve the issue, the DSD and CDM are responsible for ensuring kitchen compliance. The surveyor inquired to the Executive Director as to what issues were found to be present with the facility dishwashing system, to which they replied: They did their testing of the strips and that was within normal limits, and the vendor came out again Friday, and same with the plumber, and I'm waiting for updates, they were looking at the booster, I would have to get back to you on that. On 12/10/24 at 9:45AM the surveyor conducted an interview with DSD #2 who reported the dishwasher booster had failed since 2021, We had planned to get the booster fixed, but for whatever reason they left us on a chemical sanitizer which was working for us, We knew it was running at 110, it fluctuates due to whatever is happening, it wasn't a steady under 110 continual, we were just notified last week the guys just told us last week the hot water wasn't as hot as it should be. Surveyor's continued review of the dishwasher temperature logs revealed the dishwasher was repeatedly not meeting minimum required temperatures and temperature re-checks were performed, with results that still did not meet minimum required temperatures during the re-checks. On 12/13/24 at 12:24PM the surveyor conducted an interview with the Operations Director #17 who acknowledged ongoing water temperature control issues and cold water flow occurring affecting the kitchen operations, and stated the facility's mixing valve issue was being looked at, and additionally stated: now we have the proper person to look at the booster and fix that.

Based on medical record review and interviews with the resident family and facility staff it was determined the facility failed to ensure that the appropriate equipment used to transfer a resident who receives dialysis was in place prior to the resident going to the scheduled dialysis appointment. This was found to be evident for 1 resident (Resident # 9) reviewed during the facility's annual Medicare/Medicaid survey. The findings include: An interview was conducted with Resident # 9's family representative Responsible Party (RP) on 12/2/19 at 12:10 PM to discuss concerns regarding the resident. The RP stated that on 11/11/19 the resident missed his/her scheduled dialysis appointment because the nurse improperly placed a sling that could not be used to transfer the resident at the dialysis facility. An interview was conducted with the Nursing Home Administrator (NHA) on 12/4/19 at 10:29 AM and she was asked about the resident not receiving dialysis on 11/11/19. The NHA stated that she recalled that this did occur. The NHA went on to say that the nurse who cared for the resident on that date was a new nurse and when asked about the sling, the nurse stated that she did not remember if she placed a sling on the resident. The NHA stated that the resident had refused dialysis in the past. The NHA returned to the survey team on 12/5/19 at 9:30 AM and stated that the nurse who cared for Resident # 9 on 11/11/19 only worked on Mondays. The NHA further explained that on this date the nurse placed the facility sling on the resident and not the sling that is used for dialysis, so the resident had to be brought back to the facility and did not receive dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was determined the facility failed to conduct a thorough investigation of a fracture of unknown origin sustained by a functionally and cognitively impaired resident (Resident #7). This was evident for 1 of 3 residents reviewed for resident's rights during this annual recertification survey. The findings included: The facility failed to thoroughly investigate the circumstances of a fracture sustained by Resident #7. Medical record review on 12/2/19 revealed that Resident #7 was a long-term care resident with diagnoses that included but were not limited to Cerebrovascular Accident (stroke), Muscle Weakness, Aphasia, a history of repeated Falls and Advanced Dementia. Review of facility reported incident #MD00133588 revealed that on 11/12/18 Geriatric Nursing Assistant (GNA) #3 noted that Resident #7 had swelling and discomfort to the right ankle. An x-ray confirmed that the resident had an acute fracture of the ankle. The facility report noted that Resident #7 had significant aphasia and was unable to report how the injury occurred. Aphasia is the loss of ability to understand or express speech, caused by brain damage. A Skin Condition Record for Non-Pressure Ulcer Skin Conditions, dated 11/12/18, noted that the resident's right ankle had light purple discoloration and edema. In a written statement, dated 11/13/18, GNA #3 documented that s/he did not note anything unusual on the morning of 11/12/18 but upon transferring the resident to the bed at 2:30 PM noticed the resident showing signs of discomfort and notified the nurse. A physician's note dated 11/13/18 reported that the resident was seen for a right ankle fracture with pain. It was noted that Resident #7 was aphasic and did not answer questions regarding pain due to advanced Dementia. Review of the annual Mimimum Data Set (MDS) assessment dated [DATE] revealed that facility staff coded the resident in Section C- Cognitive Patterns, as severely cognitively impaired. The assessment noted that the resident utilized a wheelchair for mobility. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. During an interview with the surveyor on 12/4/19 at 2:15 PM the Director of Nursing (DON) stated the facility hosted nursing students on the unit the weekend of 11/10/18 -11/11/18. The surveyor inquired if statements were obtained from the students assigned to the resident or the instructor. The Director of Nursing stated that she spoke to the instructor who did not report anything that would be considered an accident. The surveyor asked if the instructor was in the room for transfers and other care and the DON responded that she did not know. The surveyor, also, inquired if transfer techniques were reviewed with nursing staff to ensure competency and safety during transfers. Further review of the facility's investigative materials failed to include interviews and education for the nursing student (s) assigned to Resident #7's care to ensure that the students received the appropriate level of supervision and adhered to the residents plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interviews with the resident family and facility staff, it was determined the facility failed to notify the resident and/or family representative in writing that they were being transferred out of the facility to the hospital and the reason for the hospital stay. This was evident for 2 (Resident # 24 and Resident # 9) of 3 residents reviewed for hospitalization during the facility's annual Medicare/Medicaid survey. The findings include: 1. An interview was conducted with the resident representative (RP) on 12/2/19 at 12:10 PM and they stated that Resident # 9 went out to the hospital on [DATE] and the facility did not provide him/her with any documentation about the transfer. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 12/4/19 at 9:55 AM and they were asked to provide a copy of the written transfer summary that was sent with the resident and that was given to the resident representative upon transfer to the hospital on [DATE]. On 12/5/19 at 9:30 AM the NHA provided the survey team with documentation that contained a face sheet, a Maryland Medical Orders for Life Sustaining Treatment (MOLST) form and a copy of physician orders for Resident # 9. There was no documentation or notes about dialysis or any other care concerns that were specific to the resident. No documentation about bed hold policy provided. The NHA was made aware that this is a concern. 2. Review of Resident #24's medical record on 12/5/19 at 11:49 AM revealed that on 4/6/19 at 8:20 PM the resident was transferred to the hospital for an evaluation of a possible seizure. Further review of the medical record failed to a reveal a written notice that the Responsible Party (RP) was notified. During an interview with the residents' RP on 12/5/19 at PM s/he stated' the facility did not inform me verbally or in writing. An additional review of the medical record, within the Clinical Note Entry dated 4/6/2019 at 11:56 PM, revealed that the resident was sent to the hospital by ambulance at around 11:40 PM. The DON and family member also notified. The medical record noted on 4/06/2019 at 10:03 PM, Awaiting response Resident call his wife and notified her of the seizure. DON notified. During an interview with the Director of Nursing on 12/6/19 at PM, she stated, the notice was not given as required, but the RP was notified.

Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (# 24) of 3 residents reviewed for hospitalization. The findings include: Review of Resident #24's medical record on 12/5/19 at 11:49 AM revealed that on 4/6/19 at 8:20 PM the resident was transferred to the hospital for an evaluation of a possible seizure. Medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party was notified in writing of the bed-hold policy. During an interview with the Director Of Nursing on 12/5/19 at 3 PM, she stated, the transfer/discharge information is included in the admission packet. When given the citation tag by this surveyor, the DON stated the information will now be given for all residents transferred or discharged from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, it was determined facility staff failed to conduct a comprehensive assessment when a significant decline occurred in the Resident #19's condition. This was evident for 1 of 3 residents reviewed for a change in condition during this annual recertification survey. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The MDS assessment directs the facility staff on issues that may need to be addressed. The findings include: Medical record review revealed that Resident #19 was admitted to the facility with diagnoses that included but were not limited to Dementia, history of Falls, Abnormal Loss of Weight, Congestive Heart failure and Chronic Kidney Disease. Review of the annual MDS assessment dated [DATE] revealed that facility staff coded the resident in Section G Functional Status G0110 A Bed Mobility and B Transfers as a 3/2 (required extensive assistance of 1 staff). Review of section K- Swallowing/Nutritional Status revealed that the resident weighed 161 pounds and no significant weight loss was noted. Review of the quarterly MDS assessment dated [DATE] revealed that facility staff coded the resident in Section G Functional Status G0110 A Bed Mobility and B- Transfers areas as a 4/3 (required the total assistance of 2 staff). In Section K-Swallowing/Nutritional Status the resident was noted to have weight loss (149 pounds) that was not physician prescribed. A Dietary Note dated 11/19/19 reported the resident's weight continued to trend down and s/he continued to trigger for significant weight loss. It was noted the weight loss was likely due to refusal of oral nutrition and advanced Dementia. The findings were discussed with the MDS Coordinator on 12/4/19 at 1:15 PM.

Based on medical record review and interviews with facility staff it was determinedthat the facility failed to complete the discharge Minimum Data Set (MDS). This was found to be evident for 1 resident (Resident # 2) when assessments were triggered to be reviewed during the facility's annual Medicare/Medicaid survey. The findings include: The MDS forms the foundation of a complete assessment of the resident which provides the facility 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. Review of the discharge MDS on 12/3/19 at 3:12 PM revealed that Resident # 2 was discharged on 7/8/19 to the Assisted Living Unit (ALU). Review of the discharge note on 7/8/19 confirmed that the resident was discharged . The facility missed opening and completing the discharge MDS. An interview was conducted with the MDS Coordinator on 12/4/19 at 1:42 PM and he stated that he reviewed the MDS and is unsure why the MDS discharge was not done. The Nursing Home Administrator (NHA) and Director of nursing (DON) was made aware of the concern on 12/4/19 at 2:00 PM.

Based on medical record review and staff interview it was determined the facility failed to develop and implement an individualized care plan that addressed the use of Paxil and Lorazepam for Resident #11. Also, it was determined the facility failed to develop comprehensive person-centered care plan for Resident #4 receiving two antidepressant medications. This was evident for 2 of 3 (R#4 & R#11) residents reviewed for care plan implementation during this annual recertification survey. The findings include: 1) The facility failed to develop care plans that clearly identified target symptoms for the use of Paxil and Lorazepam. Medical record review on 12/4/19 revealed that Resident #11 was a long-term care resident with diagnoses that included but were not limited to Anxiety Disorder, Recurrent Depressive Disorder and Dementia. The medical record contained a care plan with a goal date of 12/24/19 with a problem statement that the resident was receiving antianxiety drugs on a regular basis. Target symptoms or the resident's expressions of anxiety were not specified. Interventions included to medicate as per the physician's order and monitor for side effects of the medication. The medications were not specified. Another care plan with a goal date of 12/24/19 addressed the resident's risk for displaying signs and symptoms of anxiety/restlessness at times and yelling and calling out for support. One intervention directs staff to monitor the side effects of medications and notify the physician, behavioral health services and/or hospice with any changes. The care plans do not identify the use of the medications and do not address depression. Review of the December 2019 Medication Administration Record revealed that the resident was receiving Paxil for Prolonged Depressive Reaction and Lorazepam for Anxiety Disorder, Unspecified. Paxil (paroxetine) is an antidepressant that belongs to group of drugs called selective serotonin reuptake inhibitors (SSRIs). Paroxetine affects chemicals in the brain that may be unbalanced in people with depression, anxiety, or other disorders. www.webmd.com Ativan (lorazepam) is used for the management of anxiety disorders, the short-term relief of symptoms of anxiety or anxiety associated with depression. Ativan is also effective for panic attacks and insomnia. www.webmd.com The findings were discussed with the Director of Nursing on 12/4/19 at 2:20 PM. 2) A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Resident #4's record was reviewed on 12/4/19 at 1:36 PM. A plan of care was developed on 2/28/19 for depression. Zoloft medication for depression. On 8/16/19 Remeron was added to the resident's medication regimen for appetite stimulate, however; a care plan was not developed and/or updated to reflect that the resident was receiving this medication as an appetite stimulant and not for depression.

Based on medical record review and interviews with the resident family and facility staff it was determined the facility failed to update a resident's care plan to include non-compliance with treatment regimen. This was evident for 1 resident (# 9) reviewed during the facility's annual Medicare/Medicaid survey. The findings include: An interview was conducted with the Resident Representative (RP) on 12/2/19 at 12:10PM to discuss concerns regarding Resident # 9. The RP stated that Resident # 9 missed a dialysis appointment on 11/11/19. The RP went on to say that the nurse improperly placed a sling on Resident # 9 and the resident had to be brought back to the facility and did not receive dialysis. An interview was conducted with the NHA on 12/4/19 at 10:29 AM and when asked about the resident missing a dialysis appointment, she stated that this did occur but also indicated that the resident has refused to go to dialysis previously. Review of the care plan on 12/4/19 revealed that Resident # 9 does not have a non-compliance care plan. In another interview with the DON on 12/4/19 at 1:00PM she confirmed that Resident # 9 does not have a care plan for refusals of care. She stated that the facility will complete one.

Based on observation and staff interview it was determined the facility staff failed to prominently post nurse staffing information to ensure that staff and visitors could easily identify staff to resident assignments. This was evident for the long-term care unit throughout this annual recertification survey. The findings include: During an initial tour of the facility on 12/2/19 at 10:10 AM the surveyor noted the staffing sheet was in a plastic photo type frame at the nurses' station. The placement of the assignment sheet was not obvious, and it was necessary to go beyond the nurses' station desk to view the assignment sheet. Subsequent observations on 12/3/19 at 8:30 AM, 12/4/19 at 11:30 AM and 12/5/19 at 8:45 AM also revealed that he assignment sheet was not posted in a size and format to permit easy reading and was not immediately visible to residents and visitors. The findings were discussed with the Director of Nursing on 12/5/19 at approximately 1:15 PM.

Based on review of employee files, training records and staff interview it was determined the facility failed to consistently ensure that all staff received abuse prevention training that included activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and Dementia management. This was evident for 2 of 4 nurses reviewed for training compliance during this annual recertification survey. The findings include: Surveyor review of a facility reported incident #MD00133588 revealed a concern about a fracture of unknown origin. The resident was diagnosed with an acute fracture of the right ankle. Surveyors often review training records of staff assigned to residents noted to have injuries of unknown origin. Review of the training records for Licensed Practical Nurse (LPN) #2, who was assigned to the resident's care on the date the injury was reported, revealed s/he did not receive the required abuse prevention and Dementia Management training for the year 2019. The training records indicated that LPN #2's training was due in January 2019. Further review of the facility's training records revealed that LPN #1 and Registered Nurse (RN) #1 failed to attend the required training for 2019. Training records indicated that LPN #1 was due to have the training in August 2019 and RN #1 in April 2019. During an interview with the surveyor on 12/4/19 at 1:58 PM the Human Resources Coordinator stated that employees are due to have required training in the month they are hired. The surveyor confirmed during an interview with the Human Resources Director on 12/5/19 at 1:30 PM that LPN #1 and #2 and RN #1 did not have the required training for 2019. The findings were discussed with the Director of Nursing on 12/5/19 at approximately 1:15 PM. Refer to F610

Based on review of employee files, training records and staff interview it was determined that the facility failed to ensure that all nurses' aides received 12 hours of training, annually, that included abuse prevention and Dementia management, and addressed areas of weakness as determined in the nurse aides' performance reviews. This was evident for 3 of 7 (GNA # 1, 2 and 3) nurses' aides reviewed for training compliance during this annual recertification survey. The findings include: Surveyor review of a facility reported incident #MD00133588 revealed a concern about a fracture of unknown origin. The resident was diagnosed with an acute fracture of the right ankle. Review of the employee file for Geriatric Nursing Assistant (GNA) #3, who was assigned to the resident's care on the date the injury was reported, revealed that s/he did not receive the required 12 hours of in-service training that included abuse prevention and Dementia Management. Further review of the facility's training records revealed that GNAs #1 and #2 did not have documentation of 12 hours of education, abuse prevention or dementia management training. During an interview with the surveyor on 12/4/19 at 1:58 PM the Human Resources Coordinator confirmed that GNA #3 did not have the required training for 2019. The surveyor confirmed during an interview with the Human Resources Director on 12/5/19 at 1:30 PM that GNAs #1 and #2, also, did not have the required training for 2019. The findings were discussed with the Director of Nursing on 12/5/19 at approximately 1:15 PM.

Based on medical record review and observation, the facility staff failed to ensure that Resident #10's walker was out of site of the resident, while in the resident's room. This was evident for 1 out of 11 residents investigated during the survey. The findings include: On 7/16/18 when interviewing Resident #10, the resident informed the surveyor that the resident had fallen down the prior week while using the walker. The resident stated that the walker had gotten away from the resident. The surveyor observed the resident's walker with wheels and a hand break, sitting alongside of the resident's bed. During review of then resident's Plan of Care it was noted that, per the resident's son the walker may remain in the resident's room, but if so, it should be folded up and out of reach of the resident. Based on the resident's son and the plan of care, the facility staff failed to maintain an accident free environment for Resident #10.

Base on the initial tour of the kitchen, it was observed that the facility failed to store food under sanitary conditions. This occurred in two locations in the kitchen area. The findings include: 1. On 7/16/2018 at 9:30 AM, this surveyor observed that the drain lines for the service sink, coffee line, ice machine and the rinse compartment of the 3 compartment sink in the kitchen area did not have air gaps between the drains and sewer flood rim. An air gap is a space between the drain and sewer flood rim (sewers drain) that prevents sewer water from backing up the drain line and causing sewer water contamination. The findings were brought to the attention of the Kitchen Manager and the Director of Dinning. Factors in these observations can lead to foodborne illnesses if sewer water backed up into an area that is used to prepare food or make ice.

Based on observation and staff, family & resident interview it was determined the facility failed to ensure that a soap dispenser in the bathroom of Resident #16 was kept filled. This was evident for 1 of 11 residents selected for review during the survey. The findings include: On 7/16/18 at 11:41 AM, Resident #16 and a family member stated that the soap dispenser in the resident's bathroom wasn't working and hasn't been working for some time. They stated that although they had informed staff, the soap dispenser still did not work. The surveyor confirmed the soap dispenser was not working. On 7/16/18 at 12:00 PM, staff #1 was brought to the bathroom and confirmed that the soap dispenser was not dispensing soap. The facility is responsible to ensure that soap dispensers are working properly so that staff and residents can practice appropriate hand hygiene.