Homewood Living Frederick

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 for life sustaining measures aligned with the MOLST and accurately reflected the resident's wishes, and 3) failed to maintain accurate medical records by failing to ensure that agency staff had the ability to document the care they provided to residents. This was evident for 1 (#86) of 3 residents reviewed for advanced directive, and 2 (#44 and #151) of 2 residents reviewed for documentation.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that resident's drug regimen included clear indication for use and frequency. This was evident for 1 (#64) of 6 residents reviewed for unnecessary medications review.

Inspectors wroteBased on observation, staff interview and facility documentation review, it was determined the facility failed to ensure that medication carts were locked when unattended. This was evident on 2 of 4 hallways observed.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to maintain accurate and complete medical records. This was evident for 2 (#27 and #26) of 32 residents records reviewed.