Every finding on record at Homewood Living Frederick

Based on record review and interview it was determined that the facility failed to thoroughly investigate self-reported incidents. This was evident for 3 (#2649305, #2689607, and #2804687) of 4 self-reported incidents reviewed during the annual survey. The findings include: 1). On 10/21/25, the facility filed a Facility Reported Incident (FRI #2649305) with the Office of Health Care Quality (OHCQ), reporting that a former resident (Resident #91) had reported to a home health care worker that while residing at the facility they had been punched by two of their care givers. The home health care worker discovered bruising on Resident #91's chest and reported the allegation to their supervisor, who then contacted the facility. The facility subsequently reported to OHCQ that the allegation could not be substantiated following its investigation. On 8/12/26 at 2:05 PM, the surveyor reviewed the facility's internal investigation of FRI #2649305. The investigation indicated that Resident #91 had been discharged from the facility on 10/5/25 and was receiving home health services after discharge. The home health nurse who initially assessed the resident on 10/14/25 documented no skin issues or bruising. Because the date of the alleged incident was not provided, the facility audited all staff members and obtained statements regarding the allegation. None of the staff statements substantiated the allegation. The facility also obtained statements from Resident #91's spouse and roommate, Resident #97. The spouse stated that when Resident #91 recalled the event, they assumed the resident was just confused. Resident #97 stated they did not see anything and had never witnessed any form of abuse. However, the surveyor found no evidence that the facility interviewed or assessed other residents to determine whether they had witnessed the alleged abuse or had experienced similar concerns. Therefore, the investigation did not include interviews with other residents who may have had relevant information regarding the allegation. On 8/12/26 at 2:28 PM, the surveyor interviewed the Administrator in Training (AIT), who was the Director of Nursing (DON) at the time of the incident and conducted the internal investigation for FRI #2649305. When asked about the facility's process for investigating allegations of abuse, the AIT stated that the investigation includes interviewing the resident, staff who cared for the resident, roommates, and others as deemed necessary. When asked specifically whether she interviewed other residents to determine if they had similar allegations or had witnessed the alleged abuse, she stated, I will now, another surveyor just talked to me about the same concern with another investigation. The AIT stated that she misunderstood the investigation instructions and mistakenly believed she only needed to interview known witnesses. She acknowledged that interviewing other residents could provide additional information and stated that she planned to improve the investigation process moving forward. 2). Narcotic (controlled) medication, due to its potential for abuse and addiction, is required to be thoroughly tracked and accounted for by the facility. On 8/12/26 at 11:00 AM a review of the facility self-report #2689607 revealed that on 12/09/25 at 3:15 PM, when the day shift Licensed Practical Nurse (LPN #6) and the evening shift LPN #16 counted narcotics located on their assigned medication cart, they discovered the Tramadol blister card for Resident #47 was missing. The corresponding narcotic count sheet indicated that 18 pills remained in the blister card. LPN #6 alleged that she must have disposed of the card after removing a dose of medication earlier in her shift because she thought it was empty. She was not sure why she thought that the blister card was empty. The report indicated that a search for the discarded blister pack failed to locate the medication. On 8/12/26 at 11:00 AM a review of the facility's investigation file revealed 5 separate witness statements: 1) a typed statement with no name, signature, or date which contained interview information with LPN #6 and the Housekeeping Supervisor (Staff #12), 2) a second typed statement with no name, signature or date that listed an order of events, 3) a handwritten statement signed by LPN #6, 4) a printed copy of an email between the unit manager (Staff #18) and the Director of Nursing (DON, Staff #5), and 5) a printed copy of an email from LPN #16 to the DON. There were no other staff or resident witness statements. Further review of the investigation file failed to reveal any evidence that the Maryland Board of Nursing was notified that narcotic medication went missing while under the control of LPN #6. A review of the staff assignment for the 7-3 shift on 12/09/26, which was provided by the Acting DON on 8/13/26 at approximately 11:00 AM, revealed that there was another nurse and 3 nursing assistants on duty on Resident #47's unit at the time the medication went missing. On 8/12/26 at 2:06 PM an interview was conducted with the AIT, to review the facility's investigation of the incident. She said that she was involved in the investigation. When asked why the blister pack of Tramadol was not found in the trash, the AIT said that the facility trash was normally compacted throughout the day and it had already been compacted by the time of the discovery of the missing medication. When asked about other witness statements, the AIT said that no other statements were obtained and that she knew this was a deficient practice and that there were other examples of incomplete investigations that were found during the current survey. She further explained that LPN #6 was sent for drug testing which was negative, and that LPN #6 was suspended during the investigation, and then terminated because she did not immediately report the missing medication. The AIT also said that Resident #47 received all scheduled doses of medication since the facility replaced the missing medication promptly. When asked if the Board of Nursing was notified, Staff #4 said she did not contact the Board of Nursing since the facility's investigation did not substantiate that LPN #6 took the Tramadol. 3) A review of facility-reported incident #2804687 contained an allegation of abuse by Resident #21 on 3/15/26, stating that a nursing assistant was physically aggressive toward the Resident, yelled at the Resident, and twisted the Resident's head. The Director of Nursing and the Executive Director (ED) were notified of Resident #21's concern on 3/15/26. A review of the facility's investigation into Resident #21's allegation of abuse included statements and interviews with the alleged perpetrator and other staff members who worked on the day of the incident. Further review of the assignment sheet for the Unit where Resident #21 resided on the day the alleged abuse occurred showed that the perpetrator cared for other residents on that day. However, the review did not demonstrate that the facility thoroughly investigated the allegation. It lacked documentation of interviews with, or assessments of, other residents in the perpetrator's care to determine whether anyone else had similar complaints. It also lacked evidence of a head-to-toe assessment of Resident #21. During an interview on 8/12/26 at 2:00 PM with the AIT, the facility's abuse coordinator, she explained that after learning of Resident #21's allegation, she interviewed only Resident #21 and not any other residents cared for by the perpetrator. Staff #4 acknowledged the surveyor's concern about the lack of a thorough investigation into Resident #21's abuse allegation. The AIT added that her investigations would improve going forward.

Based on record review and interview it was determined that the facility failed to ensure narcotic medications were kept under control when a blister pack of 18 Tramadol (narcotic medication) pills was unable to be located. This was evident for 1 self-reported incident (#2689607) of 4 self-reported incidents reviewed during the annual survey.The findings include:Narcotic (controlled) medication, due to its potential for abuse and addiction, is required to be thoroughly tracked and accounted for by the facility.Review of the facility's policy titled Controlled Substance Policy, revealed the statement that for shift-to-shift count and reconciliation, two licensed nurses will conduct the count. The oncoming nurse will hold the package to ensure package integrity and count the number of pills/bubbles (whether whole or halved) and the licensed nurse going off shift will review the Controlled Substance documentation form and provide the count left to the oncoming nurse.On 8/12/26 at 11:00 AM a review of the facility self-report #2689607 revealed that on 12/09/25 at 3:15 PM, when the day shift Licensed Practical Nurse (LPN #6) and the evening shift LPN #16 counted narcotics of their assigned medication cart, they discovered the Tramadol blister card for Resident #47 was missing. The corresponding narcotic count sheet indicated that 18 pills remained in the blister card. LPN #6 alleged that she must have disposed of the card after removing a dose of medication earlier in her shift. She was not sure why she thought that the blister card was empty. A search for the discarded blister pack failed to locate the medication.On 8/12/26 at 11:00 AM a review of the facility's investigation file revealed a witness statement written by LPN# 16 that stated [LPN# 6] opened the [narcotic] box, brought out the medications and asked me to wait a few minutes to cross-check that she properly signed all the narcotics she administered. During this process she discovered that [Resident #47's] Tramadol was missing. [LPN# 6] noted from the book that she gave a pill out from the card and signed for it, but couldn't find the card containing the rest of the medications. At this time she became confused and started searching everywhere but was unable to find it. Another nurse came over to assist her with the search without any success. Further review of the investigation file revealed that although a search was conducted of the trash on the nursing unit, the facility's dumpster, and LPN #6's possessions, the medication was never located. The file also contained evidence that the local police were notified and investigated this incident - which included camera recordings, and that the Drug Enforcement Agency was also notified.On 8/12/26 at 2:06 PM an interview was conducted with the Administrator in Training (Staff #4), who was the former Director of Nursing (DON). When asked why the blister pack of Tramadol was not found in the trash, Staff #4 said that the facility trash gets compacted throughout the day and it had already been compacted by the time of the discovery of the missing medication. She further explained that LPN #6 was sent for drug testing which was negative for the medication that was missing. Staff #4 also said that LPN #6 was initially suspended during the investigation and was later terminated for not immediately reporting the missing medication. She further explained that Resident #47 received all needed doses of medication since the facility replaced the missing medication promptly.On 8/12/26 at 2:23 PM an interview was conducted with the Housekeeping Supervisor, Staff #12, and she was asked if the housekeeper, Staff #14, was interviewed or had her possessions searched. Staff #12 said that LPN #6 had told Staff #14 to search for a missing ring and after Staff #14 searched but did not find anything she left the facility. Staff #12 then contacted Staff #14 by phone and informed her that medications were missing and that moving forward only nurses would empty the medication cart trash. Staff #12 further stated that Staff #14 no longer worked at the facility.On 8/13/26 at 10:40 AM an interview was conducted with the Acting DON (Staff #2) and she was asked what steps were taken after the incident. She explained that the facility changed their process so that only nurses emptied the medication cart trash, and that all nurses were educated regarding the new process. She also said that all nurses were re-educated regarding proper narcotic medication storage and monitoring. She added that the facility's pharmacist conducted monthly random audits of narcotic medication storage and documentation for 3 months after the incident and then continued to conduct quarterly audits.

Based on observation and interview, it was determined that the facility failed to ensure staff practiced infection prevention and control measures in the laundry area. This was evident for 1 of 1 laundry area and has the potential to affect all residents.1) An observation in the laundry area on 7/17/25 at 8:54 AM revealed Laundry Aid #15 was in the washer room (dirty area) and failed to wash or sanitize her hands when she came to the clean side. She took a pile of clean towels from the folding table, placed them on a cart and then continued to fold laundry.An interview was conducted with Laundry Aid #15 at the time of the observation on 7/17/25 at 8:54 AM. When asked she confirmed she had not washed or sanitized her hands when leaving the dirty area to come to the clean area. In addition, she continued to fold clean laundry without sanitizing or washing her hands after it was brought to her attention.On 7/17/25 at 9:00 AM Housekeeping Supervisor #16, Project Manager #17, and Environmental Services Director #18 were made aware of the observation and the employee continuing to fold clean laundry. She stated the laundry aid should have washed or sanitized her hands. She stated she would address this concern immediately.2) On 7/17/25 at 8:11 AM an observation of the laundry area was conducted. The area where dirty laundry was received had a stack of boxes on the floor in the right corner adjacent to the doorway. There were refill bottles of Purell hand sanitizer and 3 packages of table clothes stored on the shelf above the dirty laundry bins. To the left, was an alcove with shelving that stored new supplies and clean items. Also, there was a labeling machine, and staff used this area to label the resident's personal clothing. A doorway separated the receiving area from the room with the washers. The door was open and there were multiple blankets and a shower curtain hanging on the door. During this observation, Laundry Aid #15 was asked if they were clean or dirty and she reported they were clean items that could not be dried so staff draped them on the door to dry. She proceeded to remove them from the door and take them to the clean side to fold and place them on a clean cart. She failed to wash her hands and started folding clean laundry.There were foam cushions without covers laying on top of a washer and a shoe. Between the washer and the wall (where the hand sink was located) there was a blue plastic bin with a sheet laying half in and half out and under it were mop heads. Also, there was a bin of mop heads beside it. Over in the corner, to the right of the doorway were mops and buckets with a sign that read, dietary mops.An observation of the clean side with the dryers revealed several linen carts that had the covers draped open and some had linen on them. The folding table had clean laundry that had been folded. There were carts with residents' personal clothing hanging in them and they were draped open. These items were potentially contaminated since there was no separation between the clean and dirty areas.A closet off the clean area had the door closed and inside were clean linens. There were 2 boxes being stored on the floor.The concerns were reviewed with the Housekeeping Supervisor #16 on 7/17/25 at 8:35 AM in the laundry area. She reported she was aware that clean supplies should not be stored in the dirty area and that boxes should not be on the floor. She stated she had taken the position over within the week and had not had time to make changes. Program Manager #17 and Environmental Services Director #18 joined the interview and were made aware of the concerns.The concerns were reviewed with the Director of Nursing at the time of exit on 7/21/25 at 2:30 PM.

Based on observation and interview, it was determined that the facility failed to maintain a safe and clean area to process the dirty laundry. This was evident for 1 of 1 laundry areas observed.The findings include:On 7/17/25 at 8:11 AM an observation of the laundry area revealed in the dirty laundry processing area there was a missing ceiling tile in the right corner adjacent to the doorway to the washer room. There were 7 ceiling tiles around this area that had brownish colored stains on them. In addition, there was dried, brownish substance stains that ran down the wall near this corner and 2 trashcans on a shelf below the area that had dried, brownish substance running down the sides of them. The shelf that held the trashcans had a dried, brownish substance on it.An interview with the Housekeeping Supervisor #16, Project Manager #17, and Environmental Services Director (ESD) #18 on 7/17/25 at 8:35 AM revealed there was a juice machine that had leaked on the floor above the area. ESD #18 reported that they were aware of the damage and the need to clean the area. The concerns were reviewed; however, he offered no rationale as to why the area had not been cleaned and repaired. The concerns were reviewed with the Director of Nursing at the time of exit on 7/21/25 at 2:30 PM.

Based on observations and staff interview during facility environmental observations, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 1 of 4 nursing units observed during the survey. The findings include: During an initial observation of Room 210's shared bathroom by 2 surveyors on 7/8/22 at 12:34 PM, and a second observation made on 7/13/22 at 10:05 AM, the following concerns were identified. a) A tall cabinet in the corner of the bathroom had a piece of wood trim missing from the bottom of the cabinet. The piece of wood trim was the width of the cabinet and approximately 1 inch high and was seen lying on the floor in front of the cabinet. b) There was a large scrape that extended across the width of the lower interior bathroom door with wood finish missing, and a smaller width scrape on the interior door above the kick-plate that extended across the width of the door with wood finish missing. c) The right-side edge of the interior door had a piece of laminate, approximately 2 inches x 1/2 inches, missing. On 7/15/22 at 12:35 PM, a maintanence secretary (#15) was made aware of the above findings. At that time, together with Staff #15, an observation of Room 210's bathroom was made, and the findings were confirmed. The Director of Nursing was made aware of the above concerns 7/15/22 at 1:00 PM.

Based on medical record review, facility documentation, and staff interview, it was determined that 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 (#17) of 1 resident reviewed that were transferred to an acute care facility. The findings include: On 7/11/22 at 11:54 AM, a review of the medical record revealed that Resident #17 was transferred to an acute care facility on 7/1/22. On 7/1/22 at 8:10 PM, in a progress note, a registered nurse (RN) #20 documented that Resident #17 was transferred to the hospital emergency room and the resident's representative was notified of the transfer. There was no written documentation found in the medical record that the resident and/or the resident's representative (RR) was notified in writing of the resident's transfer along with the reason for the transfer. On 7/15/22 at 11:23 AM, during an interview with Licensed Practical Nurse (LPN) #12 she stated that, when a resident was transferred to the hospital, a transfer notification and bed hold policy was sent with the resident and a copy of the form would be in the resident's chart. On 7/15/22 at 11:30 AM, Unit Secretary (#13) indicated that a copy of Resident #17's transfer notice must not have been made for the resident's chart, and the DON (Director of Nursing) would look for a copy in the hospital records. On 7/15/22 at 11:40 AM, the DON provided the surveyor with a copy of a Notice of Transfer/Bed-Hold/Removal of Belongings form for Resident #17, dated 7/1/22, and stated that the notice would be sent with the resident on transfer, and the admission department called the family the next day. Review of the transfer notice form revealed documentation that a copy was sent with Resident #17 when transferred to the hospital on 7/1/22 , that the RR was called and informed of the transfer/bed-hold, along with the information on the form. The transfer/bed-hold notice form included the statement, Resident Representative provided a copy (if applicable) and the statement, If applicable, copy of transfer/bed-hold mailed following notification by phone. Both the statements had a date response line, that was left blank, indicating the RR was not notified in writing of the resident's transfer. On 7/15/22 at 1:10 PM, during an interview with Admissions Director (#18) she stated that, when a resident was transferred to the hospital, the RR would be called about the bed hold policy. At that time, the admissions director stated that a copy of the transfer notice was not mailed to the RR nor was the RR notified in writing regarding the reason for the transfer

Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare and document a resident's preparation for a transfer to the hospital. This was identified for 1 (#17) of 1 resident reviewed for hospitalization . The findings include: On 7/11/22 at 11:54 AM, a review of the medical record revealed Resident #17 was transferred to an acute care facility on 7/1/22 and later readmitted to the facility. There was no documentation found in the medical record that Resident #17 was oriented and prepared for the transfer in a manner that the resident could understand and there was no documentation of the resident's understanding of the transfer in the medical record. The Director of Nursing was made aware of the finding on 7/15/22 at 11:40 AM.

Based on review of the medical record and interview with facility staff it was determined the facility staff failed to provide the resident/resident's representative with written notice of the facility's bed hold policy when the resident was transferred to a hospital. This was evident for 1 (#17) of 1 resident reviewed for hospitalization . The findings include: On 7/11/22 at 11:54 AM, a review of the medical record revealed Resident #16 was transferred to an acute care facility on 7/1/22. In a progress note on 7/1/22 at 8:10 PM, a registered nurse (RN) #20 documented that Resident #17 was transferred to the hospital emergency room and the bed hold policy was sent with the resident. There was no documentation found in the medical record to indicate the resident's representative was provided written notice of the bed hold policy at the time of the resident's transfer. During an interview on 7/15/22 at 11:23 AM with Licensed Practical Nurse (LPN) #12, she stated upon a resident's transfer to the hospital, a transfer notification with bed hold policy was sent with the resident and a copy of the form would be in the resident's chart. On 7/15/22 at 11:30 AM, when asked if Resident #17's paper chart had a copy of his/her 7/1/22 transfer notice with bed hold policy, Unit Secretary (#13) she stated there was not a copy of the form in Resident #17's paper chart and indicated the DON (Director of Nursing) would look for a copy in the hospital records. On 7/15/22 at 11:40 AM, the DON provided the surveyor with a copy of a Notice of Transfer/Bed-Hold/Removal of Belongings form for Resident #17 dated 7/1/22 and stated that the notice was sent with the resident on transfer, and the family would be called by admission department on the next day. Review of the transfer notice form revealed documentation that a copy was sent with Resident #17 upon discharge on 7/1/22, that the RR was called and informed of the transfer/bed-hold, along with the information on the form. The transfer/bed-hold notice form included the statement, Resident Representative provided a copy (if applicable) and the statement, If applicable, copy of transfer/bed-hold mailed following notification by phone. Both the statements had a date response line, that was left blank, indicating the RR was not provided written notice of the bed-hold policy. On 7/15/22 at 1:10 PM, during an interview, Admissions Director (#18), stated that when a resident was transferred to the hospital, the RR would be called about the bed hold policy. At that time, the admissions director confirmed that at the time of transfer of a resident for hospitalization , written notice of the bed-hold policy had not been provided to the resident representative.

Based on review of the medical record and interview with staff, it was determined that the facility staff failed to provide residents/representatives with a copy of their baseline care plan. This was evident for 2 (Resident #17 and #76) of 26 residents whose care plan were reviewed. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. A baseline care plan must be prepared for all residents within 48 hours of a resident's admission. Its purpose is to provide the minimum healthcare information necessary to properly care for a resident until a comprehensive care plan can be completed for the resident. The baseline care plan, along with a summary of their medications, is given to the resident/resident representative and details a variety of components of the care that the facility intends to provide to that resident. This allows residents and their representatives to be more informed about the care that they receive 1) Resident #76's medical record was reviewed on 7/14/22 at 10:06 AM. The record revealed that the resident was admitted to the facility in June 2022 after surgical repair of a fractured left hip. The residents' diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record review revealed that a baseline care plan was developed for Resident #76, the completion date was documented as 6/20/22. The space for staff to document the date that the plan was reviewed with the resident/representative was blank. There was no signature of the staff member who initially completed the plan of care. The plan was not signed nor dated by the resident nor their representative to indicate that the plan was reviewed with them and that they were provided a copy of the physicians' orders, MAR (Medication Administration Record) and TAR (Treatment Administration Record). The form was signed and dated by a Social Worker (#3), indicating that the plan of care was updated on 6/21/22. The baseline care plan was signed and dated as discontinued on 6/29/22 by Licensed Practical Nurse (LPN) #12 due to completion of the comprehensive care plan. Further review of the medical record failed to reveal documentation to indicate that the baseline care plan was reviewed with the resident and their representative or that they were provided with a summary of the plan including, but not limited, to the resident's goals, medications, dietary instructions, and any services and treatments to be administered by the facility staff and other providers to assist the resident in reaching their goals. These findings were reviewed with the Director of Nursing in an interview on 7/14/22 at 10:06 AM. She indicated that the Unit Clerk was in the process of scanning documents into the electronic medical record and that there may be additional documentation reflecting that the baseline plan of care was reviewed and provided to the resident/representative. She returned a short time later and indicated that she was unable to find additional documentation. 2) On 7/11/22 at 11:54 AM, a review of Resident #17's medical record revealed documentation that Resident #17 was readmitted to the facility on [DATE] following an acute hospitalization . A base line care plan for Resident #17, with a readmitted [DATE], revealed documentation that the base line care plan was reviewed with the resident/representative on 7/5/22. There was no documentation in the base line care plan form, or in Resident #17's medical record, to indicate that the facility provided the resident and their representative with a copy of the baseline care plan and a summary of their medications. The above concerns were discussed with the Director of Nursing on 7/15/22 at 1:00 PM

Based on record review and interview it was determined that the facility 1) failed to implement comprehensive person-centered resident care plans by failing to ensure that agency Geriatric Nursing Assistants (GNAs) were aware of resident's care needs and preferences, 2) failed to ensure that resident care plans described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being by failing to ensure that a Wander Guard device was included in the plan of care for a resident identified as an elopement risk. This was evident for 3 (#25, #51, and #76) of 26 residents whose care plan were reviewed. The findings include: 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. MDS (Minimum Data Set) is 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. Brief Interview of Mental Status (BIMS) is a standardized test used to get a quick snapshot of the cognitive function and is a required screening tool used in nursing homes to assess cognition. A score of 13-15 points indicates an intact cognition, 8-12 points indicates moderately impaired cognition, and 0-7 points indicates severely impaired cognition. 1 a) A medical record review for Resident #76 on 7/13/22 at 10:31 AM revealed an MDS, with an assessment reference date of 6/20/22, that documented in section C, Resident #76 scored a 1 out of 15 on the BIMS which indicated the resident had severe cognitive impairment. In section G, it was documented that Resident #76 was dependent on the staff for daily care needs. Further review of the medical record revealed a care plan: [Resident #76] was alert with confusion related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan for resident's daily care needs included, but was not limited to, the following interventions: resident prefers the recliner, maintain a neatly made bed, resident requires a maximum of 2 assist with bed mobility, dressing, and personal hygiene. The behavior care plan interventions included, but were not limited to, speak concisely and repeat as needed, please talk to me [Resident #76] in a calm manner, try to talk to me during daily care, and if I [Resident #76] become physically abusive then walk away and try care later. A review of the Willow unit assignment sheet for the Agency GNAs on 7/13/22 at 9:40 AM revealed that the facility failed to add Resident #76's care needs and preferences beside his/her name. 1 b) Resident #25's medical record was reviewed on 7/13/2 at 11:18 AM. Review of the MDS, with an assessment reference date of 5/3/22, revealed in section C resident had scored on the BIMS, a 4 out of 15, which indicated severe cognitive impairment. Section G documented that the resident was dependent on staff for daily care needs. A review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply A and D ointment to affected skin surfaces every day to moisturize. Further review of the medical record revealed a care plan for psychosocial wellbeing with interventions that included but were not limited to, talk to me [Resident #25] about my past, I [Resident #25] like classical music and reading, listen to my fears and gently clarify misconceptions, speak in simple phrases, if I have physical behaviors towards staff then give me space and reapproach later. A review of the Willow unit assignment sheet for Agency GNAs on 7/13/22 at 9:40 AM revealed that, beside Resident #25's name it was noted, A&D ointment to BLE (bilateral lower extremities which mean both lower legs.) The instructions written in the order to cleanse the legs before applying the A&D ointment were not included. In addition, information from the care plan regarding preferences and care needs had not been added. On 7/13/22 at 9:40 AM, Unit Clerk (UC) #6 revealed that they do not print the resident's care plans for [NAME] or Key Court for the Agency GNAs, instead they are provided with an assignment sheet. During an interview with an agency GNA #9 on 7/14/22 at 9:09 AM, she/he stated that she relied on the report received from the off-going GNA and the information on the assignment sheet to provide care to residents. She stated that, at times, she approached to the resident and asked them how they transferred or if they were able to stand. Also, GNA #9 was asked about Resident #76's specific needs and preferences. She had been unable to verbalize them. Furthermore, she reported she had been upset that the off going GNA had not reported to her that Resident #76 had a broken hip. She reported that she found out later in the shift when she went to the nurse to report the Resident had been in pain. Furthermore, when asked about Resident #25's care needs and preferences, GNA #9 reported that she had Resident #25 on her assignment. GNA #9 was unable to verbalize the residents' specific needs and preferences as stated in the care plan. She stated that she had figured out the resident liked to be complimented. An interview with the Director of Nursing (DON) on 7/14/22 at 10:41 AM revealed that the facility had identified an issue with agency GNAs using their access to the resident's EMR, therefore they had stopped providing the access. When shown the assignment sheet for Key Court she stated that the residents on that unit were short term and they had not put any information regarding the resident's preferences and care needs on the assignment sheets because the off going GNA was to provide the information to the agency GNA. When shown the assignment sheet for [NAME], the DON reported that the charge nurse was responsible for documenting the care needs and preferences they felt the agency GNA needed to know. DON was shown that the information for Resident #76 had not been added and the information for Resident #25 had not been complete. 2) A Wander Guard system utilizes bracelets and a door alarm system to alert staff when residents with memory impairment attempt to wander into unsafe areas. When the bracelet comes in close proximity of a door on the system an alarm will sound. Resident #51 was observed on 7/13/22 at 12:36 PM in the dining room, eating lunch. A Wander Guard bracelet was in place on his/her left ankle. The resident's sock was pulled over the bracelet. In an interview at that time Unit Clerk #6 and Registered Nurse #16 indicated that all Wander Guard bracelets worn by the residents are visually checked by the nurse for placement every shift and that the night shift nurse checks each bracelet every night to make sure they are working properly. They indicated that the nurse signs both of these activities off on the resident's TAR (Treatment Administration Record) when completed. They also indicated that the batteries were replaced as needed. Resident #51's medical record was reviewed on 7/14/22 at 9:37 AM. The resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission elopement assessment identified Resident #51 as an elopement risk and indicated that the elopement prevention intervention implemented at that time was Secure Unit. The next elopement assessment, completed 6/7/22, again identified Resident #51 as an elopement risk. The elopement prevention interventions identified at that time were Secure Unit and Wanderguard bracelets. The Additional Comments section of both assessment forms indicated Interventions must be included on nursing care plan. Further review of the record revealed physician orders, written 5/24/22, for Check wander guard placement every shift and Check wander guard for proper function nightly. Resident #51's Admission Baseline Care Plan, dated 5/24/22, revealed on page 2 Elopement risk. The interventions Apply wander guard bracelet if I am exit seeking was checked off. A comprehensive Plan of Care for behavior was dated 6/2/22, and included: I have a tendency to wander related to my progressing dementia and recent transition to a new environment. The resident's goal was to remain safe during periods of wandering behaviors and reduce his/her wandering episodes to less than once a day. 6 interventions were identified, however, the plan did not include the Wander Guard bracelet, nor the care and services related to the Wander Guard such as checking for placement and functioning as ordered by the physician. A plan of care for Pressure Ulcers, dated 6/1/22, included I am at risk for Pressure Ulcers/Skin Injury related to new admission, poor appetite, incontinence and poor safety awareness. This plan of care included 15 interventions. Neither plan identified the Wander Guard on Resident #51's ankle as a potential risk for skin injury that should be monitored. During an interview on 7/14/22 at 10:50 AM, these concerns were reviewed with the Director of Nursing.

Based on observation, medical record review and interview, it was determined the facility failed to ensure that oxygen tubing was labeled when initiated. This was evident for 2 (Resident #24 and #17) of 2 residents reviewed for respiratory care. The findings include: 1) On 7/8/22 at 9:30 AM, an observation was made of Resident #24, lying in bed, wearing an oxygen NC (nasal cannula) whose tubing was connected to an oxygen concentrator set at 2.5 lpm (liter per min). The NC oxygen tubing was not labeled with the date it was initiated or changed. On 7/12/22 at 2:05 PM, a review of Resident #24's medical record was conducted. Review of Resident #24's June 2022 MAR (medication administration record) revealed a 4/17/22 order for Oxygen 2-4 liters via NC or face mask as needed for SOB (shortness of breath) or restlessness every shift, that was documented as administered every day in June. Also, in the resident's June 2022 MAR, was a 2/6/22 order to Change NC q (every) 2 weeks prn (as needed) when in use with no documentation to indicate that Resident #24's oxygen nasal cannula tubing had been changed in June 2022. Review of Resident #24's July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, Resident #24's July MAR, had an order to Change NC q (every) 2 weeks prn (as needed) when in use with no documentation to indicate that Resident #24's oxygen nasal cannula tubing had been changed in July 2022. 2) On 7/8/22 at 12:22 PM, an observation was made of Resident #17, lying in bed, wearing a nasal cannula whose tubing was connected to an oxygen concentrator set at 2 lpm. The NC tubing was not labeled with the date it was changed. On 7/11/22 at 11:54 AM, a review of Resident #17's medical record was conducted. Review of Resident #17's July 2022 TAR (Treatment Administration Record) revealed a 7/6/22 order for Oxygen at 2 lpm via NC routine for SOB (shortness of breath) every shift, that was signed off as administered on 7/6/22 and 7/7/22, then discontinued on 7/7/22. A new order placed on 7/8/22 for Oxygen at 2 lpm via NC routine for SOB (shortness of breath) that was signed off every shift since 7/8/22. Resident #17's July 2022 TAR also had an order to Change n/c q (every) 2 weeks on Sundays and PRN (as needed) when in use, every 2 weeks. The order was initiated on 7/6/22 and had a start date of 7/24/22. There was no documentation found in TAR to indicate when Resident #17 last had his/her nasal cannula changed. In addition, the 7/6/22 order indicated the oxygen tubing was to be changed every 2 weeks, however, the 7/24/22 start date was 19 days after the initiation of the order which was greater than 2 weeks. On 7/13/22 at 10:07 AM, a second observation of Resident #17 revealed the resident wearing an oxygen nasal cannula whose tubing was connected to an oxygen concentrator that was set at 2 lpm. On 7/13/22 at approximately 3:00 PM, the above concerns related to facility staff not labeling oxygen tubing when initiated or changed were discussed with the DON (Director of Nursing). At that time, the DON indicated that the expectation was for oxygen tubing to be changed every 2 weeks and provided the surveyor with the facility's Policy and Procedure for Oxygen Safety, Policy #NS 073, with revised date 11/2018. The facility's oxygen safety policy procedure included 3. Oxygen in use: d. make sure the tubing is labeled with the date of initiation and f. oxygen cannula and tubing is changed every 2 weeks by 11- 7 shift. The nurse will sign off on the MAR/TAR when the tubing is changed. The above concerns were discussed with the DON on 7/13/22 at 4:08 PM.

Based on review of medical records, facility policies, and interviews, it was determined that the facility failed to ensure that narcotics removed from the resident's supply were administered as evidenced by staff documentation of the removal of narcotics without a written explanation of the need for the narcotic, or documentation on the Medication Administration record that the narcotic was administered to the resident. This was found to be evident for 2 out of 2 residents reviewed for pain management. The findings include: [MEDICATION(S)] and [MEDICATION(S)] are narcotic pain medications. Narcotic pain medications are potent and effective at managing moderate to severe pain but have significant side effects and the potential for abuse. As a result, facilities are required to track the medication carefully and be able to reconcile administered doses of [MEDICATION(S)] and [MEDICATION(S)] with evidence of that medication's dispensation. Controlled substance records include purchasing and shipping records, inventories, usage and disposal logs, and disposal paperwork. 1) A review of controlled substance records also known as the controlled sheet for Resident #67 was conducted on 7/14/22 at 09:50 AM. Resident #67 had two different prescribed narcotic medications, [MEDICATION(S)] 15 mg three times per day and [MEDICATION(S)] ([MEDICATION(S)]- Acetaminophen 10-325 mg) every 8 hours as needed. An interview was conducted with Licensed Practical Nurse (LPN) #14 on 7/14/22 at 11:16 AM. She stated that for the use of Narcotic medication, staff needed to fill out the controlled sheet (name of the person giving, date, time, amount. on hand, amount. received, amount given, and amount remaining) and document under MAR (Medication Administration Record). Further review of the controlled sheet and MAR for Resident #67 revealed that some medications were dispensed from the narcotic box and signed on the controlled sheet. However, there was no documentation in Resident #67's medical records to indicate the medication was administered to the resident on the following occasions 6/26/22 at 2 PM, controlled sheet signed by a nurse for [MEDICATION(S)]. No documentation under MAR 6/30/22 at 10 PM, controlled sheet signed by a nurse for [MEDICATION(S)]. No documentation under MAR 6/25/22 at 4:50 PM, controlled sheet signed by a nurse for [MEDICATION(S)]. No documentation under MAR 6/26/22 at 10:50 AM, controlled sheet signed by a nurse for [MEDICATION(S)]. No documentation under MAR 7/7/22 at 8:30 AM, controlled sheet signed by a nurse for [MEDICATION(S)]. No documentation under MAR 7/9/22 at 10:29 AM, controlled sheet signed by a nurse for [MEDICATION(S)]. No documentation under MAR On 7/14/22 at 12:47 PM, the surveyor reviewed the concern with the Director of Nursing (DON) that dispensed narcotics were not documented on MAR. As of the time of exit on 7/15/22, no additional information had been provided regarding these concerns. 2)Review of Resident #57's medical record on 7/14/22 revealed the resident was admitted in 2021 with diagnoses that included, but were not limited to chronic pain syndrome. The resident has orders, in effect since 2021, for [MEDICATION(S)]-Acetaminophen 7.5 - 325 ([MEDICATION(S)]) to be given every 6 hours as needed (PRN) for severe pain. Further review of the medical record revealed a Controlled Substance Record for 45 [MEDICATION(S)] received on 5/25/21. The Controlled Substance Record includes information as to when the supply of the narcotic was received, and the total number of doses received. There are spaces for nursing staff to document the date and time a dose was removed, the amount on hand, the amount given (removed) and the amount remaining. There is also an area for the nursing staff who removed the narcotic to sign their name. Review of the Medication Administration Record (MAR) revealed areas for nursing staff to document the resident's reported pain level at the time of the prn [MEDICATION(S)] administration. Review of the Controlled Substance Record for the [MEDICATION(S)] delivered in May 2021 revealed that one dose was removed on 3/24/22, one dose on 4/7/22, one dose on 5/26 and two doses on 6/13/22. Review of the MARs failed to reveal documentation to indicate the the doses removed from the supply on 3/24, 4/7, 5/26 or 6/13 were administered to the resident. Further review of the medical record failed to reveal documentation to indicate the resident had required, requested or received this narcotic pain medication. On 7/14/22 on 4:49 PM, surveyor reviewed the concern with the DON regarding the removal of the narcotic from the supply without documentation of the need for or the administration of the medication. Cross reference to F 761

Based on medical record review and interview with facility staff, it was determined that the facility failed to ensure that pharmacists' recommendations after a medication regimen review were followed up on in a timely manner and filed in the resident's medical record. This was evident for 1 (#24) of 5 residents reviewed for unnecessary medications. The findings include: On 7/12/22 at 8:30 AM, a review of Resident #24's medical record revealed that the consultant pharmacist reviewed the resident's drug regimen every month and made a recommendation on 12/9/21. Continued review of the medical record failed to reveal what the 12/9/21 pharmacist's recommendations included. On 7/12/22 at 2:00 PM, the DON (Director of Nursing) was made aware of these findings and a copy of the recommendation was requested. On 7/12/22 at 2:52 PM, the DON stated that the facility never received the written recommendation from the 12/9/21 medication regimen review, so the DON contacted the pharmacy and was told that the pharmacy's internal review indicated that the pharmacist made a recommendation on 12/9/21 for Resident #24, however, the pharmacy could not locate the written recommendation.

Based on medical record review and interview, it was determined that the facility failed to ensure residents were free from unnecessary medications as evidenced by failing to document a resident's pain assessment before administering pain medication. This was found to be evident for 1 (Resident #67) of 2 residents reviewed for pain management during the survey. The findings include: On 7/14/22, review of Resident #67's medical record revealed that the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/14/22 at 12:55 PM, a review of the care plan for Resident #67 stated, assess me for pain every shift using a 0-10 scale with 10 as the greatest as an intervention related to the resident's pain. However, further review of the medication records for June 2022, and July 2022 revealed that as-needed (PRN) medication was administered to the resident without pain assessment on multiple occasions including: On 6/7/22 at 4:44 PM, medication was administered without note or comments On 6/10/22 at 12:50 PM, medication was administered without notes or comments. On 6/11/22 at 11:55 AM, medication was administered without notes or comments. On 6/19/22 at 01:11 AM, medication was administered, noting resident medicated with PRN [MEDICATION(S)]. Medication effective. On 7/4/22 at 07:02 AM, medication was administered without notes or comments. On 7/11/22 at 10:05 AM, medication was administered without notes or comments. On 7/12/22 at 8:48 PM, medication was administered without notes or comments. On 7/14/22 at 4:57 PM, the surveyor reviewed the concern with the Director of Nursing (DON) regarding the failure to document pain assessments before administrating PRN medication. On 7/15/22 at 7:00 AM, the DON submitted some interdisciplinary notes regarding to the PRN [MEDICATION(S)]. Further review of the medical record, including interdisciplinary notes, failed to reveal documentation to indicate that a pain assessment was completed or the resident requested the prn pain medication on the occasions listed above.

Based on review of medical records, policies, observations and interviews, it was determined that the facility failed to ensure that expired medications were removed from the resident's supply. This was found to be evident for 1 out of 2 residents reviewed for pain management and 1 out of 4 medications carts observed. The findings include: 1) On 07/15/22 09:45 AM, the surveyor made the following observation while performing the facility task of Medication Storage and Labeling. During the examination of the following medication cart on the unit titled: The Meadows, the following discovery was found: Hallway A Medication Cart: The surveyor in the presence of the unit manager, Staff #12 observed that, in the first drawer of medication cart found one (1) Insulin pen syringe labeled for Resident #17 and the medication [MEDICATION(S)] 100 units hich was dated opened on 02/16/22 and additionally a discard date of 03/16/22. The medication was ordered by the physician for the insulin pen was written on 02/14/22, and the medication was ordered to be discontinued on 02/16/22. During an interview with the unit nurse manager, (#12) she stated that the outdated insulin pen should not have been in the medication cart drawer because the medication was expired and that the resident was not receiving the medication. The insulin pen belonging to Resident #17 was removed from the medication cart by the unit manager (#12) in the presence of the surveyor. Review of the electronic medical record on 07/15/2022 at 11:55 AM revealed that resident #17 's discontinuation order for the medication was written on 02/16/22. Review of the facility's Storage of Medications Policy with a revision date of November 2020 stated on line #4: Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. The director of nursing of was advised of the deficiency at 11:55 AM on 07/15/22 prior to the exit conference. 2) Review of Resident #57's medical record on 7/14/22 revealed that the resident was admitted in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had orders, in effect since 2021, for [MEDICATION(S)]-Acetaminophen 7.5 - 325 ([MEDICATION(S)]) to be given every 6 hours as needed (PRN) for severe pain. [MEDICATION(S)] ([MEDICATION(S)]-Acetaminophen 7.5 - 325) is a narcotic pain medications. Narcotic pain medications are potent and effective at managing moderate to severe pain but have significant side effects and the potential for abuse. As a result, facilities are required to track the medication carefully and must be able to reconcile administered doses of [MEDICATION(S)] with evidence of that medication's dispensation. Further review of the medical record revealed a Controlled Substance Record for 45 [MEDICATION(S)] received on 5/25/21. The Controlled Substance Record includes information regarding the narcotic, including when it was received, and the total number of doses received. There are spaces for nursing staff to document the date and time a dose was removed, the amount on hand, the amount given (removed) and the amount remaining. Further review of the Controlled Substance Record revealed that the supply of [MEDICATION(S)] received in May 2021 expired on 5/20/22. According to the Controlled Substance Record, as of 5/20/22, five doses of the [MEDICATION(S)] remained in the supply. One dose was documented as removed on 5/26/22, two doses were removed on 6/13/22 and one dose on 6/24/22. As of 6/24/22, one dose of [MEDICATION(S)] remained from the supply delivered in May 2021. On 7/14/22 at 3:44 PM, review of the current Controlled Substance Record located on the medication cart on the unit revealed that a supply of 13 [MEDICATION(S)] was delivered on 5/3/22. On 7/15/22 at 7:00 AM, the DON reported the last dose from the May 2021 supply was currently in the destroy box. Surveyor reviewed with the DON that the expiration date was 5/20/22 for this supply of [MEDICATION(S)] and that doses had been removed after the expiration date. Cross Reference to F 755

Based on medical record review and staff interview, it was determined the facility failed to keep complete and accurate medical records as evidenced by 1) failing to void a resident's MOLST form when an updated MOLST form was completed, 2) failed to ensure that a resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evident for 1 (#86) of 3 residents reviewed for advanced directive, and 2 (#44 and #151) of 2 residents reviewed for documentation. The findings include: Maryland MOLST (Maryland Orders for Life Sustaining Treatment) is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. If an updated MOLST form is completed, all older forms shall be voided in accordance with the MOLST's instructions: Voiding the Form: To void this medical order form, the physician, NP, or PA shall draw a diagonal line through the sheet, write VOID in large letters across the page, and sign and date below the line. A nurse may take a verbal order from a physician, NP, or PA to void the MOLST order form. Keep the voided order form in the patient's active or archived medical record. 1) On [DATE] at 11:38 AM, a review of Resident #86 medical record revealed that Resident #86 had 5 MOLST forms in the medical record with no indication that any of the MOLST forms had been voided. In Resident #86's paper medical record there was one MOLST form that was signed and dated [DATE] which documented that Resident #86 elected No CPR, Option A-2, Do Not Intubate (DNI): comprehensive efforts may include limited ventilatory support and do not intubate (insertion of a breathing tube for mechanical ventilation). In Resident #86's EMR (electronic medical record), under attachments, were 5 MOLST forms and none of the MOLST forms were voided: a) There was a MOLST form that was signed and dated [DATE], which documented that Resident #86 elected Attempt CPR if cardiac and/or pulmonary arrest occurs, attempt CPR. b) There was a MOLST form that was signed and dated [DATE], that documented Resident #86 elected Attempt CPR if cardiac and/or pulmonary arrest occurs, attempt CPR c) There was a MOLST form that was signed and dated [DATE], that documented Resident #86 elected Attempt CPR if cardiac and/or pulmonary arrest occurs, attempt CPR d) There was a MOLST form that was signed and dated [DATE], that documented Resident #86 elected No CPR, Option 2, Do Not Intubate. e) There was a MOLST form that was signed and dated [DATE], that documented Resident #86 elected No CPR, Option 2, Do Not Intubate. The MOLST, signed and dated [DATE], was the same as the MOLST found in the resident's paper medical record and was Resident #86's most recent, active MOLST. On [DATE] at 10:40 AM, the DON (Director of Nursing) was made aware of the above concerns. At that time, during an interview, the DON stated that when a new MOLST was created for a resident, the old paper MOLST would be voided and placed in the resident's back-up record in the facility's medical records. The DON stated that, in the EMR (Electronic Medical Record), the facility was unable to void scanned documents or void a PDF (portable document format) file, so the old MOLST would be given an inactive date, and indicated that nurses knew to select the link active attachments only and not select all active files in the EMR. 2) Resident #86's medical record review revealed that Resident #86's most recent, active MOLST form was signed and dated [DATE], with documentation that Resident #86 elected No CPR, Option A-2, Do Not Intubate (DNI): comprehensive efforts may include limited ventilatory support and do not intubate Review of Resident #86's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order indicated Resident #86 would want to be resuscitated with CPR, which was inaccurate as Resident #86's most recent MOLST documented Resident #86's elected code status was No CPR, Option 2, Do Not Intubate. On [DATE] at 11:06 AM, the above concerns were discussed with the DON. 3) During this survey, the surveyor was made aware of a complaint from an anonymous source that Geriatric Nursing Assistants (GNA) assigned to Key Court, while working with an agency GNA was told by Administration that they were to document the care provided by the agency GNA in the electronic medical record (EMR). The complainant stating that when the agency GNA provided the care they were to let the staff GNA know so the staff GNA could enter the care into the EMR even when they had not witnessed or assisted with the care. The complainant reported that when assigned to [NAME] unit or Meadows unit the agency GNAs had a notebook to document on paper the care they provided. On [DATE] at 10:05 AM a review of the notebook at the nurses' station on [NAME] unit revealed flowsheets for the residents residing on the [NAME] unit. There wasn't a notebook for Key Court. On [DATE] at 10:06 AM Unit Clerk #6 reported that the notebook was for the [NAME] unit and there was no notebook for Key Court unit. Unit Clerk #6 reported that they always made sure a staff GNA was assigned with the agency GNA, on Key Court, so the staff GNA could complete the documentation in the EMR. Unit Clerk #6 reported that there were so many different agency GNAs that they stopped giving them access to EMR. The Director of Nursing (DON) was interviewed regarding the process on [DATE] at 12:17 PM. She confirmed that the expectation was to have the agency GNA work with a staff GNA and the staff GNA would document all the care provided. When asked if the agency GNA performed the care without the staff GNA present then would the expectation be the same. She stated that yes, the staff GNA was expected to document the care after receiving a verbal confirmation from the agency GNA that it had been done. DON reported it was no different than a nurse documenting something that was reported to them. When asked if there was a narrative option for GNAs to document it had been reported to them versus them providing the care. She verbalized there was a comment section, however stated there was no policy/procedure to guide nursing assistants on how to document and there had been no education regarding the process for documenting for the agency GNA. An interview with GNA #7 on [DATE] at 9:35 AM, revealed she had worked with an agency GNA the week before and had documented in the EMR the care provided by the agency GNA even when she had not witnessed or assisted with the care. GNA #7 stated this had made her uncomfortable, but she was told by Administration that she was to document for the agency GNA on Key Court. GNA #7 reported that she had last worked with an agency GNA last week and the documentation in the EMR looks as though she had been only person assigned to Key Court that day. On [DATE] at 11:42 AM a review of the staffing schedules for the week of [DATE] - [DATE], revealed that agency staff had been assigned to Key Court on [DATE] and [DATE]. On 7//,d+[DATE] for day shift agency GNA #10 was assigned to Key Court. On [DATE] for day shift agency GNA #11 was assigned to Key Court. A record review for Resident #151, conducted [DATE] at 11:27 AM revealed the Point of Care (POC) documentation in EMR for [DATE] and [DATE], revealed that care provided to Resident #151 was documented by GNA #7. According to the staffing schedule agency GNA #10 had been assigned to care for Resident #151 on [DATE] and agency GNA #11 had been assigned to care for Resident #151 on [DATE]. This confirmed that GNA #7 had documented for the agency GNAs on both of those days as she reported in her interview. Therefore, the medical record was inaccurate as GNA #7 had not provided the care. A record review on [DATE] at 12:00 PM for Resident #44 revealed the POC documentation in the EMR for [DATE] and [DATE] indicated that GNA #7 had cared for Resident #44 when in fact agency GNA #10 had been assigned to provide Resident #44's care on [DATE] and agency GNA #11 had been assigned on [DATE]. This confirmed GNA #7 had documented for the agency GNAs on both of those days as she reported in her interview. Therefore, the medical record was inaccurate as GNA #7 had not provided the care. A subsequent interview on [DATE] at 10:41 AM with the DON revealed they had changed the process on Key Court for agency GNAs to have paper charting as they were doing on [NAME] and Meadows nursing units. DON was made aware of the concerns.

Based on observation and staff interview, it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by 1) failing to ensure that resident care equipment was clean and in good repair, and 2) failing to follow hand hygiene procedures while providing wound care as evidenced by failure to wash/sanitize his/her hands when moving from dirty to clean wound care activities, failing to wash/sanitize hands after reaching into his/her pocket and removing, then replacing a marker pen and scissors, failing to sanitize scissors used to cut dressings applied to a resident's wound, and failure to complete hand sanitation between glove changes. This was evident of 1 or 4 nursing units, and 1 (#17) of 3 residents reviewed for pressure ulcers. The findings include: 1) On 7/8/22 at 12:34 PM, an initial observation by 2 surveyors of room [ROOM NUMBER]'s shared bathroom revealed that a soft, padded, vinyl toilet seat riser was on top of the commode's toilet seat. The vinyl on the left side of the toilet seat riser had multiple areas of cracked vinyl, with rough edges and exposed padding. A second observation of room [ROOM NUMBER]'s shared bathroom on 7/13/22 at 10:05 AM, revealed the same finding. Cracks in the padded toilet seat had the potential to trap urine and other body fluids and create a breeding ground for bacteria. The maintenace secretary (#15) was made aware of the findings on 7/15/22 at 12:35 PM and, at that time, with the surveyor, observed room [ROOM NUMBER]'s bathroom and confirmed the findings. 2) On 7/11/22 at 11:54 AM, a review of Resident #17's medical record revealed that the resident had a right groin wound and a pressure ulcer (injury to skin and underlying tissue from prolonged pressure) on his/her coccyx (bottom of the spine/tailbone) which required daily wound dressing treatments. On 7/13/22 at 11:40 AM, an observation of Resident #17's groin wound, and coccyx wound dressing change was made by 2 surveyors. The wound care was provided by Licensed Practical Nurse (LPN) #14 who was the wound nurse. During the procedure to change Resident #17's groin wound dressing, with gloved hands, LPN #14 removed the old dressing from the resident's groin, then washed his/her hands and applied gloves. LPN #14 reached in his/her pocket, removed a marker pen, dated the outer foam dressing to be applied to the resident's wound, and returned the marker to his/her pocket. With the same gloves on, LPN #14 opened a package of [MEDICATION(S)] Blue Classic dressing (an antibacterial dressing), then reached in his/her pocket and removed scissors. With the same gloves on, and without washing/sanitizing hands, LPN #14 removed a sheet of the blue dressing from its packaging and holding the blue dressing in his/her hand, cut the dressing to fit with the scissors and placed the dressing on the opened inner package then returned the scissors to his/her pocket. With the same gloved hands, LPN #14 opened a saline bullet (single-use vial of saline), squeezed the contents onto the blue dressing. LPN #14 then opened a skin prep pad (protective wipe that forms a barrier between the patient's skin and adhesives) and applied the wipe to the skin around the resident's wound. LPN #14 then removed his/her gloves, washed hands and applied new gloves. After changing Resident #17's groin dressing, the resident's coccyx wound dressing change was observed by 2 surveyors. At that time, wearing the same gloves applied following Resident #17's groin wound dressing change, LPN #14, along with a GNA (geriatric nursing assistant), positioned the resident in the bed and LPN #14 picked up the resident's urinary drainage bag and moved it to the other side of the bed. LPN #14 then removed the old dressing from the resident's coccyx wound. Without washing/sanitizing hands, LPN #14 applied new gloves, opened a package of 4x4 gauze pads, removed the pad, dipped in wound cleanser, then placed the pad on the resident's coccyx wound. LPN #14 removed gloves, washed hands, replaced gloves, applied skin prep to the skin around the wound, and placed a drape (protective pad) under the resident's buttocks. LPN #14 then reached in his/her pocket, removed a marker pen, dated the outer foam dressing, returned the marker to his/her pocket and removed scissors. Without washing/sanitizing his/her hands, or sanitizing scissors, LPN #14 opened a package of Calcium alginate with silver (highly absorbent, antimicrobial dressing), and holding a sheet of the alginate in his/her hands, cut a piece of the alginate, laid it on the resident's coccyx wound, then covered the wound with the outer foam dressing. The above concerns were discussed with the Director of Nurses on 7/15/22 at 1:00 PM.

Based on review of facility and resident records, and interview with facility staff, it was determined the facility staff failed to implement interventions to prevent a cognitively impaired vulnerable resident from leaving the facility unsupervised. This failure placed the resident at risk for serious injury, serious harm, serious impairment or death. Corrective measures were implemented by the facility and completed as of 6/27/21 resulting in a finding of past non-compliance. This was evident for 1 (#1) of 12 residents on elopement precautions. The findings include: Facility reported incident #MD 915 was reviewed on 3/14/22 at 8:00 AM. A review of the resident's record revealed that Resident #1 was a cognitively impaired resident with diagnoses that included, but were not limited to, dementia, altered mental status and repeated falls. His/Her BIMS (Brief Interview of Mental Status) assessment scorer was 6/15 on 6/3/21. A BIMS is an assessment that provides a quick snapshot of cognitive function. A BIMS score of 0-7 is considered severe cognitive impairment. Resident #1 resided on the unlocked Meadows Unit located on the second floor. The resident's record revealed a nursing progress note, written 3/4/21 at 3:16 AM, which indicated, Resident getting out of bed and wandering up and down the hall with no assistive device. Unable to redirect. Pleasantly confused, gait unsteady. During an interview on 3/16/22 at 12:09 PM, the Administrator confirmed that Resident #1 propelled himself/herself in a wheelchair but was ambulatory as well. A progress note written on 5/24/21 at 11:57 PM revealed that Resident #1 was observed twice near the volunteer desk, which was located on the first floor near the front entrance of the facility. A WanderGuard bracelet was paced on the resident's wheelchair at that time due to the resident refusing to wear it on his/her person. A WanderGuard system utilizes door alarms that sound when an electronic WanderGuard bracelet passes near a door on the system. In an interview on 3/15/22 at 12:32 PM, Staff #5 the Director of Maintenance confirmed that WanderGuard alarms were in place at the fire doors located in the main hallway between the Long-Term Care (LTC) units and the elevator on both of the LTC floors. Review of the facility reported incident on 3/14/22 revealed that, on 6/1/21 at 6:26 PM, Resident #1was observed by the receptionist as he/she exited the elevator and walked out of the facility. A statement dated June 1st, 2021 by Staff #4, a receptionist, confirmed: On the evening of June 1st at around 6:25 pm I noticed a [man/woman] getting off the elevator and left through the HCC (Health Care Center) desk entrance. [He/She] was wearing jeans and a light jacket, no red flags went up because [he/she] was walking fine and all dressed so I assumed that [he/she] was maybe just a visitor leaving. It never dawned on me [he/she] was a resident, nothing stood out to cause me to be concerned and no alarm went off when [he/she] was exiting through the door. Staff #4's statement also indicated that Resident #1's spouse arrived at the reception desk at approximately 7:40-7:45 PM and indicated that Resident #1 was at a house down the road and needed to be picked up. Review of a statement signed by Staff #2, the evening shift nurse supervisor, indicated that she observed the resident outside of the building through a second-floor window at 6:27 PM. She went downstairs, out the front door, and observed the resident getting into a car with a woman. Staff #2's statement indicated that she failed to verify at that time that the resident was appropriately signed out of the facility. Her statement also indicated that Resident #1's spouse called and informed her that he/she received a call that the resident was at the caller's house. Her statement indicated that she and Staff #3 a Geriatric Nursing Assistant (GNA) picked Resident #1 up in Staff #3's car and returned him/her to the facility, and that Resident #1 was unable to provide a consistent account of how he/she traveled to that location. The resident was noted by staff to have no distress or injuries upon return. During an interview on 3/15/22 at 4:00 PM, Staff #2 confirmed her statement but added that she did not actually see Resident #1 get into the car. She explained that she saw a woman getting into a car and assumed that Resident #1 got into the car as well. A telephone interview was conducted with Staff #3 on 3/16/22 at 11:37 AM. She confirmed the location where she and Staff #2 picked Resident #1 up on 6/1/21, and that it was on the other side of the 4-lane divided highway. She indicated that the resident was unable to explain how he/she had gotten to that location. Review of Google Maps revealed the location where Resident #1 was picked up was 1.3 miles away from the facility. A resident with severe cognitive impairment and mobility concerns who wanders outside of the facility unsupervised has the potential to encounter hazardous situations to include but not limited to a nearby 4 lane highway, falls, and ill intention of other. The facility's failure to ensure the development of resident specific interventions to prevent a cognitively impaired resident from leaving the building unsupervised; and failure to establish a system for identification of residents leaving the building unsupervised; and failure to establish a system for identification of residents leaving the facility resulted in a finding of Immediate Jeopardy. The facility implemented the following corrective measures with a completion date of 6/27/21, resulting in a finding of past non-compliance. Staff #2 performed a head-to-toe assessment of Resident #1 upon return to the facility on [DATE]. No injuries were found, and the resident was not in distress regarding the incident. Completed 6/1/21. Staff #2 removed Resident #1's WanderGuard bracelet from his/her wheelchair and placed it on Resident #1's left ankle. Completed 6/1/21. 30-minute checks were initiated for Resident #1 on 6/1/21. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) reviewed and updated the Elopement Prevention Program policy and procedure to include that once a resident has been identified as a risk for elopement, they will have if appropriate - A WanderGuard bracelet placed on their person or wheelchair depending on mobility/ambulation status, if the resident refuses on that shift then each shift needs to keep trying and documenting attempt; - Thumbnail picture will be placed on an Elopement Risk Identifier and will be placed at the reception area, each nurse's station and in each department; and Any resident leaving the building for any LOA (Leave of Absence) needs to be signed out at the nurses station by their responsible party. The thumbnail photos were updated at all desks. Completed 6/2/21. The DON re-evaluated all Resident's on elopement precautions for proper placement of WanderGuard bracelets. Thumbnail photos were updated at all desks. Completed 6/2/21.

Based on record review and interview, it was determined that the facility had failed to develop comprehensive COVID-19 vaccination policies and procedures that addressed all the required components to ensure that all staff were fully vaccinated by failing to have, 1) a definition of co-workers and business partners that included all staff mandated to be fully vaccinated for COVID-19, 2) a process for ensuring the implementation of additional precautions for all staff who were not yet fully vaccinated or have a medical or nonmedical exemption, 3) a process by which all facility staff would have their COVID-19 vaccination information collected, secured, and tracked and to include any booster doses, 4) a hiring process for ensuring that all staff hired were fully vaccinated for COVID-19, 5) a process for medical and non-medical exemptions, for the COVID-19 vaccination, that have been requested and granted to ensure that all required documentation was collected, secured, and tracked, 6) a process for tracking and securing documentation of the COVID-19 vaccination status for staff for whom COVID-19 vaccinations must be temporarily delayed. This was evident during a complaint survey with the potential to affect all residents. The findings include: On 3/14/22 at 8:34 AM, a review of the facility's COVID 19 Vaccination Policy for Licensed Nursing Home Co-Workers, dated 8/20/21, with the last revision date of 1/14/22 and the COVID - 19 Business Partner Vaccination Policy dated 11/10/21 was conducted. The facility defined co-workers as individuals, who work in or are expected to enter the Healthcare Center, however, it was unclear that co-workers cover all individuals mandated to be fully vaccinated. The facility failed to define who was considered a business partner. The facility policy stated that co-workers with an approved medical or nonmedical exemption for the COVID-19 vaccination will be required to wear a face-covering and other appropriate personal protective equipment (PPE) as determined by the facility's management, however, the facility failed to include a process to ensure that these additional precautions were implemented. In addition, the facility failed to include additional precautions for staff who were not fully vaccinated due to the hiring process, had a temporary delay, and the policies had not included information for their business partners who had staff who had not been fully vaccinated due to a temporary delay in vaccination, new hire, or medical or nonmedical exemption. The facility had a section in the policy outlining the documentation that was required to verify the COVID-19 vaccination status, which included allowing staff who did not have proof of their vaccination status to sign an attestation that they had the vaccination, which was not an approved method to verify staff COVID-19 vaccination status. Furthermore, the facility failed to provide a process for collecting, securing, and tracking all staff ' s COVID-19 primary vaccination status and any booster doses received. The facility failed to provide a process for collecting and securing documentation and tracking newly hired staff's COVID-19 vaccination status or their status for requesting a medical or nonmedical exemption. The facility failed to include in the policy a process for reviewing and approving the medical and nonmedical exemptions and identifying the documentation required for the exemption. A review of a medical exemption for staff #6 on 3/15/21 at 9:25 AM, revealed that he physician had noted the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, further review of the facility's policy COVID-19 Business Partner Vaccination Policy dated 11/10/21, revealed the facility failed to include a process by which the facility had been ensuring that all business partners were notified of vaccination requirements and the way in which they would collect and secure the information received from the business partners. The policy stated that the facility would not be collecting the actual proof of vaccination or the exemption forms, but was requiring the business partner to collect and maintain the proof of vaccination status or medical or nonmedical exemption for each staff member. However, the facility had not established a process to ensure that they were aware of each individual's vaccination status and able to ensure that additional precautions had been implemented for the individuals who were not fully vaccinated due to new hire process, temporary delays for vaccination, or a medical or nonmedical exemption for the COVID-19 vaccination. The facility had not included in the COVID-19 vaccination policies and procedures a way to track staff with a temporary delay in COVID-19 vaccinations. During an interview with the Assistant Director of Nursing and the Nursing Home Administrator on 3/18/22 at 7:30 AM, the concerns regarding the COVID-19 Vaccination policies and procedures were discussed. The Nursing Home Administrator stated that they would review and update the policies to meet the regulatory requirements.

Based on record review and staff interview, it was determined that the consultant pharmacist failed to identify unclear physician's medication orders and refer them to the physician and nursing. This was evident for 1 (#64) of 6 residents reviewed for unnecessary medications review. The findings include: Resident #64's medical record was reviewed on 11/7/18 at 2:07 PM and revealed a physicians' order for [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) to be given as needed for increased tremors. The order did not include how often the medication should be administered. The record revealed 2 orders for [MEDICATION NAME] 650 mg (milligrams) for fever over 100. One of the orders was for tablets by mouth and the other for rectal suppository, neither order indicated how staff should determine when to administer the tablet or a suppository. The monthly consultant pharmacist reviews failed to reflect that the pharmacist had identified the above discrepancies and referred them to the physician and nursing to address. The Director of Nursing was made aware of these findings on 11/7/18 at 4:09 PM.