Moran Nursing and Rehabilitation Center

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure allegations of abuse are thoroughly investigated. This was evident for 3 (Resident #38, #25, #64) of 6 residents reviewed for abuse.

Inspectors wroteBased on record review and interviews it was determined the facility staff failed to 1.) ensure resident care was supervised 24 hours per day by licensed nursing staff and failing to ensure medications were administered as ordered by the physician and 2.) ensure physician order for weekly blood sugar check was performed. This was evident for 1 (#MD00214955) of 12 complaints and 1 of 5 (#8) residents reviewed for unnecessary medications reviewed during the survey.

Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to offer the current COVID-19 vaccination or document the refusal for the current COVID vaccine for residents. This was evident in four (Resident #63, # 20, #11, #18) out of five residents reviewed for immunization status.

Inspectors wroteBased on observations and interview it was determined that the facility failed to maintain a clean and sanitary environment as evidenced by ceiling tile discolored with black and fuzzy white substance. This was evident for 1 combination shower/bathrooms of 2 observed during a survey.

Inspectors wroteBased on observation, interview, review of facility reported incidents and facility policy, it was determined that the facility failed to treat a vulnerable resident with respect and free from verbal and physical abuse. This was evident during a recert/complaint survey and investigation review of 2 of 11 facility reported incidents involving alleged abuse (R #407 ).

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure comprehensive assessments were coded accurately. This was evident for 1 (Resident #8) of 7 residents reviewed for accidents.

Inspectors wroteBased on record review and staff interview, it was determined facility staff failed to provide adequate supervision for residents during care to prevent accidents. This was evident for 1(404) of 6 residents reviewed for accidents/hazards.

Inspectors wroteBased on record review and interview it was determined that the facility failed to have an effective system in place to be sure policies and procedures were in place and physician orders were followed for residents who required chest tube care. This was evident for 1 complaint (#MD00200327) of 12 complaints investigated during the recertification survey.

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure the maintenance of essential kitchen equipment, as evidenced by failure to ensure that the walk-in refrigerator door would routinely close. This was evident for one out of one walk-in refrigerator observed in the kitchen.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident, but not limited, for 3 (#35, #57, #72) of 5 residents reviewed for hospitalization and 1 (#20) of 8 residents reviewed for accidents.

Inspectors wroteBased on review of employee files and interviews, it was determined that the facility failed to have a system in place to ensure that newly hired nursing and geriatric nursing assistants (GNA) demonstrated skills competency prior to being allowed to work independantly with residents and failed to ensure that nurses were only allowed to work with active current nursing licenses. This was found to be evident for 3 out of 3 GNAs (Staff #11, #12, and #10) and 2 out of 3 nurses (Staff #13 and #15) hired in the past year and chosen for review.

Inspectors wroteBased on medical record review and staff interview, it was determined that facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#71) of 5 residents reviewed for unnecessary medications and for 1 (#57) of 3 residents reviewed for dental concerns.

Inspectors wroteBased on surveyor observation, medical record review, and resident and staff interview, it was determined that the facility staff failed to develop and implement a resident centered care plans. This was evident for 2 (#71, #57) of 3 residents reviewed for dental, and for 1 (#35) of 8 residents reviewed for accidents.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that the discharge care plan was updated to reflect a change in the discharge goal. This was found to be evident for one out of three (Resident #73) closed record reviews.

Inspectors wroteBased on medical record review, observation and interview, it was determined that the facility failed to ensure that the functionality of a wanderguard was checked on a regular basis. This was found to be evident for 2 out of 3 residents (Resident #33 and #74) reviewed for documentation of wanderguard presence and functionality. A wanderguard is an electronic device that is either worn by the resident or is attached to the resident's wheelchair that alerts staff when the resident approaches an alarmed exit.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to provide a physician ordered dietary supplement as ordered. This was found to be evident for 1 out of 3 residents (Resident #33) reviewed for nutrition/hydration.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure pharmacist consults were addressed in a timely manner. This was found to be evident for one out of seven resident's (Resident #11) reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to ensure that a psychotropic medication prescribed as needed was limited to 14 days or had a specific duration with rationale for an extended time period documented in the medical record. This was evident for 1 (#222) of 1 residents reviewed for Hospice and end of life.

Inspectors wroteBased on observation, it was determined the facility failed to properly store medications as evidenced by 1) failing to ensure that blood glucose strip containers were dated when opened, and, 2) failing to ensure that medication was properly labeled and dated. This was evident in 1 medication room observed and 1 of 2 medication carts observed.

Inspectors wroteBased on observation, resident interview, record review, and staff interview, it was determined that the facility failed to have a process in place to ensure residents received routine dental care when concerns were identified. This was evident for 1 (#57) of 3 residents reviewed for dental concerns.

Inspectors wroteBased on family interview, medical record review and staff interview, it was determined the facility failed to keep complete and accurate medical records by failing to accurately document a resident's dental status. This was evident for 1 (#71) of 1 residents reviewed for dental.

Inspectors wroteBased on observations, review of daily staffing records, and staff interview, it was determined that the facility failed to post the total number and actual hours worked by categories of Registered nurses (RN), Licensed practical nurses(LPN), and Certified geriatric nurse aides (GNA) per shift and failed to have the staff data available in an accurate clear and readable format.