Dennett Road Manor

F-F602.

The findings include:

Review on 3/3/25 at 10:30 AM of the facility reported incidents #MD00214913 and #MD00214911 revealed concerns related to narcotic discrepancies and misappropriation.

According to facility reported incident #MD00213420 occurring on 1/9/25, a family brought medications from home to the facility for Resident #302, which included Ativan (sedative). Unfortunately, about a week or so

after they were discharged home, they alleged that the Ativan bottle they brought home no longer contained Ativan but metformin (diabetic medication). They called the facility and complained. The facility did an investigation and was unable to determine if there was a mix-up with the medication but did implement new policies for residents bringing in medications from home. This also initiated the first round of education provided to the nurses regarding narcotic medications and the increase in audits of the narcotic logs by the Assistant Director of Nursing (ADON) and Director od Nursing (DON).

Interview on 3/3/35 at 11:21 AM with the facility ADON revealed that the administration started to notice a pattern with a specific nurse, so they started to watch her and the narcotic logbook closely. It was during this audit that the DON and ADON found a questionable signature on a narcotic log from 1/3/25 that LPN #14 forged.

'A pattern of incorrect documentation, missing forms, missing medication, and false documentation was identified by DON and ADON and later identified to only occur on the days when staff LPN #14 worked and completed the forms. They realized that the pharmacy sheets that came in and out were not matching and

they found a pattern only where this specific nurse worked.'

According to the facility investigation packet, reviewed on 3/3/25, LPN #14 was interviewed regarding the DON's findings and initially denied any wrongdoing but had confirmed that she signed another nurse's signature on one of the pharmacy narcotic forms.

The facility's investigation determined that there was Tramadol (narcotic for moderate-severe pain) taken from Resident #1 and Gabapentin (anticonvulsant/nerve pain medication) from Resident #17.

The facility implemented an ad hoc quality assurance and performance improvement meeting on 1/13/25 related to this concern of drug diversion with LPN #14.

The plan included:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 5 215216 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215216 B. Wing 03/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dennett Rehab Center 1113 Mary Drive Oakland, MD 21550

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Educate all nurses on the floor

Level of Harm - Minimal harm or Do not accept any medications from a resident's home stock potential for actual harm Two nurses need to sign for all narcotics that come into the building from pharmacy. Residents Affected - Few Only the management team can destroy any controlled medications.

The shift-to-shift count sheet must be completed every time the keys change hands even if the nurse leaves and goes

out of the building for lunch.

We are to use BLACK ink only

DO not scratch out or write over any mistake made on the count sheets or shift to shift report. Cross out the mistake

with one line initial and write error. DO not write over any numbers. If you write the wrong number put one line

through it, initial it, write error and write the correct number.

The shift-to-shift count sheets need to stay in the binders until collected by management.

The controlled substance sheets, when completed need placed in the med room, in the allotted spot.

Education for all nurses was completed on 2/28/25 according to the sign in log

Observation of the narcotic logs with the ADON on the 100 unit on 3/3/25 at approximately 11:45 AM noted no concerns with the narcotic logs or the signatures. There were no noted holes or discrepancies for March or February for this log.

On 3/4/25 at 8:35 AM Agency LPN #9 was interviewed regarding the process of completing the narcotic log, sign in and sign out with another nurse. She stated that you count the cards and the pills in the card and sign with the nurse.

There was a new narcotic log implemented as per the ad hoc meeting and there were no concerns or holes or errors noted. This surveyor asked the process for discrepancies, and LPN #9 stated that they recount, look for the medication then immediately report to the ADON or DON.

Interview with the DON on 3/5/25 at 10:37 AM regarding what initiated that concern with LPN #14 and the discrepancies. She stated the same as the ADON, that around 2/12/25 something seemed off. When they came in on 2/17/25 they did an audit and looked at the nurses' signatures and it appeared that one of the signatures was not that nurse's actual signature and that was the straw' then they realized paper was missing and others were remade by LPN #14.

LPN #14 was terminated from the facility on 2/21/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 215216 Department of Health & Human Services Printed: 09/07/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215216 B. Wing 03/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Dennett Rehab Center 1113 Mary Drive Oakland, MD 21550

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 30428 potential for actual harm Based on observation, interviews, record reviews, and policy reviews, the facility failed to follow infection Residents Affected - Few control and prevention guidelines as follows: The facility staff did not don (put on) personal protective equipment (PPE) prior to entering a resident room and providing hands on care. This was evident during the random observation of staff to resident interactions and patient care. This failure had the potential to affect

the spread of infections and involved Resident (39)

The findings include:

During the tour of the facility and observation of resident and staff practices, on 3/3/25 at approximately 12:45 PM, this surveyor observed LPN #3 in the room of Resident #39, with Resident #39 and GNA #4. Resident #39 was due for nutrition to be administrated via the gastrostomy tube (medical device that provides a direct route to the stomach for nutrition and medication). At this time s/he was very active and not responsive to the requests from LPN #3 to sit and let her administer the fluid bolus. GNA #4 was attempting to hold Resident #39's right arm and they both hollered for assistance. GNA #5 then came to the room to assist with the feeding administration. When LPN #3 saw this surveyor at the door observing the event in Resident #39's room, she yelled for the door to be closed. This surveyor waited outside the door until all 3 staff members exited the room.

Upon exiting the room, this surveyor asked what PPE the 3 of the staff wore while providing care. LPN #3 stated we had our gloves

and masks on, did you see he was flailing trying to head butt me?

It was reviewed at that time that there was an Enhanced Barrier Precaution sign on Resident #39's door and no one was wearing the appropriate PPE, which included according to the sign and the facility policy to the donning of gowns prior to the interaction with Resident #39s' gastrostomy tube, especially if they knew the potential of his/her behaviors and potential rejection of care that LPN #3 reported upon exiting the room.

The DON and NHA were notified of the observations during the survey and again during exit on 3/5/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 215216