**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 9/13/22 at 9:51 AM, the surveyor observed medication stored in medication cart #1 on the [NAME] Oak unit in the presence of Certified Medication Aide (CMA) #43. The top drawer contained an open bottle of acetaminophen 500mg with no date written to indicate when the bottle was opened. The surveyor observed medication stored in medication cart #2 of the Sycamore unit. A bottle of Benadryl 25mg was opened but had no open date on the container. Licensed Practical Nurse (LPN) #7 recalled the bottle was opened yesterday and labeled the bottle. A bottle of aspirin EC (enteric coated) 81mg was noted to have a manufactured expiration date of 8/22/22. The surveyor brought this to the attention of LPN #7 and she threw the bottle away. On 9/13/22 at 10:32 AM, during observation of the [NAME] Oak medication storage room, the surveyor found a box of expired heparin flushes, with expiration date of 6/7/22. This box was labeled for a resident who was identified by LPN #26 as having been discharged in January 2022. Ongoing observation of the [NAME] Oak medication storage room revealed two large bags containing approximately 50 heparin syringes in each bag. The syringes in both bags had expiration dates in 2021. Further observation of the storage room revealed a box of heparin syringes labeled with the expiration date of 3/17/22, for a resident identified by LPN #26 as having been discharged in 2021. However, the individual prefilled syringes had a manufacturer expiration of 2023. LPN #26 was present during the medication storage observation and was made aware of all the expired medications. LPN #26 then disposed of the expired medications. 3) On 08/30/22 at 10:51 AM tour of the Sycamore Unit, the surveyor observed Resident #54 in their room wearing an oxygen tubing without a label. On 8/30/2022 at 10:56 AM tour of the Sycamore Unit, the surveyor observed Resident #36 in their room wearing oxygen tubing without labeling on it. On 8/30/2022 at 11:15 AM LPN #6 with surveyor in Resident #54's room to confirm the oxygen tubing without a label. LPN #6 stated the oxygen tubing will be changed and labeled. On 08/30/2022 at 11:30 AM LPN #6 with surveyor in Resident #36's room to identify the oxygen tubing without a label. LPN #6 stated the oxygen tubing will be changed and labeled. During a subsequent tour of the nursing unit with LPN #6 on 8/30/2022 12:30 PM, surveyors identified dirty filters on the oxygen concentrators in Resident #36 and Resident #54's rooms. The filters were covered in dark gray lint-like substance and the structure of the filters were not identifiable. LPN #6 confirmed the findings during observations. On 9/7/2022 at 10:10 AM the surveyor held an interview with the Maintenance Director regarding who is responsible for maintenance of resident oxygen concentrators in the facility. The Maintenance Director stated that the oxygen concentrators are leased equipment and the Unit Managers are responsible for reporting maintenance issues with the concentrators to the maintenance department via a written report. On 9/7/2022 at 10:52 AM the surveyor interviewed the Administrator who was made aware of the surveyor's observations during the tour of the Sycamore Unit. The Administrator stated that the oxygen concentrators in the facility are scheduled for maintenance once a complaint or work order is submitted by nursing staff then once the maintenance department is aware, the maintenance department would contact the leasing company for the oxygen concentrators. On 9/12/2022 at 11:30 AM the surveyor reviewed a document provided by the Administrator titled the Facility Assessment Tool. Page six of the section titled, Physical Environment revealed that routine preventative maintenance of the oxygen tanks and equipment is scheduled by the Maintenance Director; The process to ensure quality and quantity of physical resources is the responsibility of the Maintenance Director in conjunction with Directors and Department managers. During an interview on 9/12/2022 at 1PM, the Maintenance Director confirmed with the surveyor that all oxygen concentrators were serviced by the maintenance department. During the exit conference on 9/21/2022, the Administrator confirmed that all oxygen concentrators were serviced by the maintenance department. Based on observation, staff interviews, and review of medical record documentation it was determined that the facility failed to maintain a safe and effective system for securing medication, treatment supplies, and hazardous medical equipment in their designated carts on nursing units with residents with documented cognitive deficits and wandering behaviors. This practice was noted on 8/31/22 and included five (5) medication/treatment carts that were observed unlocked and unattended. The facility's failure to secure medications and treatment supplies was evident throughout the facility's two (2) nursing units. The deficient practice was observed on 4 out of 4 medication carts and 1 of 3 treatment carts. Additionally, the facility failed to ensure that 2. medications and biologicals were labeled with and dated after opened and medications stored in medication storage areas were unexpired. This was evident for 2 out of 3 medication carts and 1 of 1 medication storage room and 3. ensure that resident nasal cannulas (oxygen tubing) were accurately labeled, and the resident oxygen concentrators were adequately serviced. This was evident for 2 (Resident #36 and Resident #54) of 13 residents reviewed during the investigative portion of the annual survey. The findings include: 1a) On 8/30/22 at 8:27 AM, the surveyor observed an unlocked and unattended and unlabeled treatment cart on the Sycamore nursing unit. The treatment cart had the following medications in it: 10 packs of povidone iodine, 1 pack of alcohol swab stick, 1 tube of Thera Honey, 1 tube of Santyl, 1 large and blue-handled pair of scissors, 1 pair of silver-handled small scissors, 2 bottles of sterile normal saline, 2 bottles of ammonium lactate 12% solution, 2 tubes of Skintegrity hydrogel, 1 tube of silver sulfadiazine cream (US 1%), 3 bottles of iodoform package strips, 1 bottle of PVP prep solution, and 1 packaged skin staple remover. During an interview that took place on 8/30/22 at 8:35 AM, licensed practical nurse (LPN) #6 stated the treatment cart was shared by herself and LPN #7 and was not aware that the treatment cart was unlocked and locked it after surveyor notification. b) During an observation that took place on 8/31/22 at 5:58 AM, the surveyor noted one medication cart and one treatment cart unlocked and unattended on the Sycamore unit near the nurse's station. During an interview conducted on 08/31/2022 at 6:00 am, the registered nurse (RN) #8 stated the medication and treatment carts had remained unlocked and unattended while he opened the side entrance to the facility. The entrance was around a corner and out of sight of both carts. The carts were not labeled with designated numbers, just identified with their immediate location on the identified unit. c) On 8/31/22 at 6:19 AM on the [NAME] Oak nursing unit, the surveyor observed a medication cart that was labeled as the Station 1 Team 1 medication cart unlocked and unattended. Further observation revealed multiple medications on top of the cart including: a yellow tablet in a medicine cup, a packaged 20mg) omeprazole tablet labeled for Resident #24, a packaged 200 mg carbamazepine labeled for Resident #10, and a bottle of extra strength 500mg acetaminophen tablets. Within the vicinity of the medication cart, approximately 10 feet, Resident #10 was observed sitting in his/her wheelchair outside his/her room facing the medication cart for an unknown time frame. The resident remained in area of the unlocked medication carts and nursing station during the continued interactions with the survey team and the nursing staff. LPN #10 was observed returning to the [NAME] Oak unit on 8/31/22 at 6:22 AM. LPN #10 was interviewed at that time and confirmed that the yellow tablet was left open in a medication cup on top of the cart but could not explain why it was there. LPN #10 stated that the yellow tablet was a Pantoprazole tablet for a resident. d) On 8/31/22 at 6:19 AM on the [NAME] Oak nursing station, a medication cart was observed in front of room [ROOM NUMBER] unlocked and unattended. Surveyor continued to observe Resident #10 wandering the unit in his/her wheelchair alone at that time. At 6:21 AM, LPN #10 was observed walking past the medication cart, turned, and then returned to the medication cart. LPN #10 placed her hand on the cart and made eye contact with this surveyor, who was still standing near the unlocked medication cart, and then LPN #10 walked away from the cart without securing it. The surveyor proceeded to verify that the cart could still be opened and observed that the cart was stocked with a variety of house stock medications as well as medications prescribed to residents in rooms assigned to the cart. On 8/31/22 at 7:50 AM a review of Resident #10's record revealed on 3/29/222 the facility initiated a care plan goal for the Resident #10 to remain free of injury related to a dementia diagnosis. On the 5/28/22 quarterly Minimum Data Set (MDS) assessment the resident scored a 0/15 on a Brief Interview of Mental Status (BIMS) assessment, indicating severe cognitive impairment. The resident was care planned to remain free of injury related to his/her dementia with an approach that states, remove resident from other residents' rooms and unsafe situations with an initiation date of 3/29/22. Resident #10 is also a noted wanderer and elopement risk based on a facility reported incident where s/he eloped from the facility. This event with Resident #10 occurred on 7/18/22. S/he had an elopement assessment completed on 7/19/2022 documenting that s/he is not aware of his/her surroundings, is confused and lacks safe decision-making capabilities. Multiple residents were observed to gather in this area where the unlocked medication carts were located, throughout the day. These observations included Resident #7 who was known to wander the facility based on surveyor observations starting on 8/30/2022. Additionally, per medical record review completed on 9/2/2022, Resident #7 had an order for a wander guard and was noted with diagnosis including schizophrenia and mood disorder and a BIMS of 3/15 indicating severe cognitive impairment. The facility policy on 'Medication Management Program,' was reviewed on 8/31/22 at 12:00 PM and stated under Security and Safety Guidelines 3. The medication cart is locked when not in use and in direct line of sight. 4. Keys to the medication room and cart are kept with the authorized staff and are the responsibility of the person assigned those keys. The Administrator and Corporate Consultant, Staff #14 confirmed that this policy, revised and effective 7/13/21 was in place and enforced. The Maryland Office of Health Care Quality (OHCQ) determined that these concerns met the Federal definition of Immediate Jeopardy, and the facility was verbally notified of this determination at 12:30 PM on 08/31/2022. The facility provided a plan to remove the immediacy while the surveyors were onsite. The removal plan was accepted by the OHCQ at 5:00 PM on 8/31/2022, after two initial plans were submitted at 3:06 PM and 3:35 PM respectively. The plan included the reeducation of the licensed nurses and certified medication aids regarding the expectation that all drugs and biologicals are to be stored in locked compartments and permit only authorized personnel to have access to the keys. The facility plans of removal included the following: if a cart is observed unlocked and unattended, staff are to lock the cart or remain with the cart until a nursing staff member is available to lock the cart. A department head or nursing manager will be assigned to validate that the carts are locked and secure and round hourly for the next 6 shifts and report the findings to the Quality Assurance Performance Improvement (QAPI). An ad-hoc QAPI meeting was held on 8/31/2022 to review and approve this plan to be completed by 9/2/2022. e) On 9/2/2022 at 7:37 AM upon entry into the facility on the Sycamore unit, Surveyor observed two (2) unlocked medication carts on opposite ends of the nursing station, approximately 10 feet on either side. LPN #7 was observed at the nursing station on the telephone. LPN #6 and RN #8 were also observed behind the nursing station talking. LPN #6 was asked if she worked last night, and she stated that she just came in to work the day shift. LPN #7 was then observed snapping her fingers at RN#8 and pointing towards the medication cart to the right, he walked over and locked it and LPN #6 then proceeded to walk to the cart to the left and lock that medication cart. RN #8 was interviewed at 7:43 AM. He confirmed that he was responsible for both medications' carts and that they were both unlocked. The facilities initial plan of removal had a completion date of 9/2/2022 that all trainings would be implemented. However, secondary to the noted observations with RN #8 the facility was placed out of compliance. These findings were reviewed with the Administrator at 9:27 AM on 9/2/22 and the OHCQ. The Administrator was notified that a new plan of removal would need to be submitted to the OHCQ. On 9/2/22 secondary to observed noncompliance with the original plan of removal the facility had to submit a new plan of removal. This plan was submitted at 12:59 PM on 9/2/22 and accepted by the OHCQ at 1:46 PM. After confirmation of the plan and implementation, the immediacy was removed, and the deficient practice remained at a potential for more than minimal harm with a scope/severity of D for the remaining residents. The second plan of removal initiated on 9/2/2022 after noncompliance was established included to discipline identified staff and re-education by the Clinical Consultant Staff #14. The facility also implemented having a department head assigned to make continuous rounds during medication pass and at a minimum of every hour for five additional shifts through 9/3/22. The facility held an ad-hoc QAPI meeting on 9/2/22 to review and approve the addendum to the plan and continue monitoring.