Every finding on record at Adams County Manor

Based on observation, record review, resident interview, and staff interview in the facility failed to maintain assistive hearing devices for Resident #101. This affected one (#101) of four residents reviewed for hearing devices. The facility census was 63.Findings include:Review of the medical record revealed Resident #101 was admitted to the facility on [DATE]. Diagnoses include acute kidney failure, psychotic disorder with hallucinations, delusional disorders, age-related macular degeneration, and anxiety disorder.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition, had verbal behaviors that occurred one to three days, did not reject care, and did not wander.Further review of the medical record for Resident #101 revealed that resident was admitted to the facility with bilateral hearing aids.Interview with Resident #101 on 08/06/2026 at 9:41 A.M. revealed that she did not have any hearing aids and did not know where they were.Interview with Director of Nursing (DON) on 08/06/2026 at 11:15 A.M. revealed that Resident #101 had hearing aids in her room and stated the resident has seen audiology since her admission to the facility.Observation on 08/06/26 at 11:20 A.M. with the DON revealed when the DON attempted to locate Resident #101's hearing aids, the hearing aids could not be found. An empty hearing aid box labeled with Resident #101's name and date of birth was located in the medication cart. When asked how long the hearing aids had been missing and when the last time they were used by Resident #101 the DON could not provide an answer and confirmed that there was no documentation of when the hearing aids were last used or where they were now. This deficiency represents non-compliance investigated under Complaint Number 3030893.

Based on record review, staff interview, review of billing records, and review of facility admission agreement, the facility failed to ensure a resident was reimbursed for an overpayment within 30 days of discharge. This affected one (#100) of three residents reviewed for resident funds. The facility census was 63. Findings include: Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] and discharged to home on [DATE]. Diagnoses included adult failure to thrive, depression, chronic obstructive pulmonary disease, and essential hypertension.Review of facility billing documents for Resident #100 reveals that billing occurred for [DATE] through [DATE] and payment was made to the facility. Resident #100 was discharged on [DATE] and was therefore owed a refund in the amount of $10,400. Refund was dispersed to Resident #100 by check dated [DATE].Interview with facility Business Office Manager (BOM) on [DATE] revealed that refunds should be made within 30 days of discharge from the facility. BOM confirmed that Resident #100 did not receive her refund within 30 days of discharge.Review of facility admission agreement stated that if [NAME] County Manor determines that an overpayment has occurred, [NAME] County Manor shall refund the overpaid amount to the resident, or if the resident is deceased , to his or her estate within thirty (30) days.This deficiency represents non-compliance investigated under Master Complaint Number 3091052.

Based on observation and staff interview, the facility failed to store food in a manner to prevent food born illness. This had to potential to affect all 69 residents residing in the facility who received food from the kitchen. The facility census was 69 residents.Findings include: 1.Observation on 03/23/26 at 9:21 A.M. of the dry storage area revealed there was a box of dried onion flakes in a bag which was unsealed and open to air. Interview on 03/23/25 at 9:22 A.M. with the Dietary Manager (DM) confirmed the onion flakes were not properly sealed and should have been discarded. 2.Observation on 03/23/26 at 9:23 A.M. of stand-up freezer #1 revealed it contained an undated bag of flour tortillas which were open to air and were undated and unlabeled and an undated and unlabeled milkshake. Interview on 03/23/26 at 9:24 A.M. with the DM confirmed the tortillas were not dated nor properly sealed and should have been discarded. The DM confirmed the milkshake was undated and unlabeled and should have been discarded. 3. Observation on 03/23/26 at 9:27 A.M. of kitchenette next to main kitchen refrigerator revealed it contained the following unlabeled and undated items: a bag of visibly spoiled lettuce, a package of cheese, a box of hamburgers. Interview on 03/23/26 at 9:28 A.M. with the DM confirmed the lettuce, cheese, and hamburgers in the refrigerator were unlabeled and undated and should have been discarded. 4. Observation on 03/23/26 at 9:29 A.M. of stand-up refrigerator #1 revealed it contained a bag of turkey lunchmeat and a bag of ham lunchmeat both unsealed and open to air. Interview on 03/23/26 at 9:30 A.M. with the DM confirmed the turkey and ham were not properly sealed and should have been discarded. 5. Observation on 03/23/26 at 9:42 A.M. of stand-up freezer #2 revealed it contained two thermometers which read 48 degrees Fahrenheit (F). The freezer contained individually packaged servings of orange juice, prune juice, and apple juice in boxes labeled to keep the juices at temperatures below 38 degrees F. The freezer also contained boxes of individually wrapped dinner rolls and doughnuts. Interview of 03/23/26 at 9:43 A.M. with the DM confirmed the freezer temperature was 48 degrees F and needed to be repaired or replaced and the facility was awaiting estimates regarding the cost of the repair. The DM further confirmed the instructions for the juices indicated they were to be stored below 38 degrees F. Interview on 03/26/26 at 3:10 P.M. with the Administrator confirmed he was aware there was a freezer in the kitchen that was being looked at to repair or replace but he was unaware that food and beverages were being stored in it. 6. Observation on 03/23/26 at 9:47 A.M. of stand-up refrigerator #4 revealed it contained an unsealed bag of cheese and a bag of thawed frozen strawberries with an open date of 03/07/26. Interview on 03/23/26 at 9:48 A.M. with the DM confirmed the cheese was not properly sealed and the strawberries had expired and both items should have been discarded. 7.Observation on 03/23/26 at 9:50 A.M of freezer #3 revealed it contained a bag of chicken fingers unsealed and open to air. Interview on 03/23/26 at 9:51 A.M. with the DM confirmed the chicken fingers were not properly sealed and should have been discarded. 8. Observation on 03/26/26 at 12:16 P.M of the refrigerator in the therapy gym used to store resident food revealed it contained meat and crackers labeled with a resident name but undated and a premade salad in a takeout container unnamed and undated. Observation of the freezer compartment revealed it contained a partially consumed milkshake open to air with no name of date and a half-gallon container of vanilla ice cream opened, unnamed and undated. Interview on 03/26/26 at 12:17 P.M. with Therapy Manager (TM) #97 confirmed the items in the refrigerator/freezer were not properly labeled and dated and should have been discarded.

Based on observation, resident interview, staff interview, and review of facility policy, the facility failed to ensure resident shower floors were maintained in good repair. This affected four (Residents #10, #11, #35, and #38) of the 24 residents sampled for showers. The facility census was 69 residentsFindings include: Observation on 03/23/26 at 1:16 P.M. revealed the shower floor in Resident #10 and Resident #11's bathroom had a large amount of water pooled on top of the tiles. Several floor tiles were cracked, grout was missing between multiple tiles, and the surface of the tiles was uneven. Observation on 03/26/26 at 9:00 A.M. revealed the shower floor in the room of Resident #35 and Resident #38's bathroom had multiple broken and/or missing tiles, and the surface of the tiles was uneven. Interview on 03/26/26 at 9:01 A.M with Resident #35 confirmed multiple tiles on the shower floor were missing or broken and the water did not drain well. Interview on 03/26/26 at 9:10 A.M with Certified Nursing Assistant (CNA) #562 confirmed the shower floors in Resident #10, #11, #35, and #38's bathrooms had missing, cracked, and broken tiles and confirmed the water did not drain correctly from the showers causing water to pool on the shower floors after the residents' showers. Review of the facility policy titled Homelike Environment undated revealed the facility encouraged the personalization and comfort of a home-like environment. This deficiency represents noncompliance investigated under Complaint Number 2647177.

Based on medical record review and staff interview, the facility failed to ensure appropriate monitoring of target behaviors for residents receiving antipsychotic medications. This affected two (Residents #6 and #20) of five residents reviewed for unnecessary medications. The facility census was 69 residents.Findings include:1.Review of the medical record for Resident #6 revealed an admission date of 04/17/23 with diagnoses including acute kidney failure, psychotic disorder, anxiety disorder, and bipolar disorder. Review of the physician's order for Resident #6 revealed an order dated 11/19/25 for Abilify (an antipsychotic medication) 10 milligrams (mg) by mouth once a day at bedtime related to psychotic disorder with hallucinations. Review of the Minimum Data Set (MDS) assessment for Resident #6 dated 12/16/25 revealed the resident was cognitively intact and received antipsychotic medication. Review of the medical record for Resident #6 revealed it did not include target behaviors and/or monitoring of behaviors related to the administration of Abilify. Interview on 03/26/26 at 12:10 P.M with Assistant Director of Nursing #490 confirmed facility staff had not identified or monitored target behaviors related to the administration of Abilify for Resident #6. 2. Review of the medical record for Resident #20 revealed an admission date of 12/17/24 with diagnoses including Wernicke's encephalopathy, alcohol abuse, psychotic disorder with hallucinations, and dementia. Review of the MDS assessment for Resident #20 dated 12/22/25 revealed the resident was was cognitively intact and received antipsychotic medication. Review of the physician's order for Resident #20 revealed an order dated 02/12/26 for Zyprexa (an antipsychotic medication 7.5 mg by mouth once a day at bedtime related to Wernicke's encephalopathy. Review of the medical record for Resident #20 revealed it did not include target behaviors and/or monitoring of behaviors related to the administration of Zyprexa. Interview on 03/24/26 at 1:50 P.M. with the Director of Nursing confirmed facility staff had not identified or monitored target behaviors related to the administration of Zyprexa for Resident #20.

Based on medical record review, observation, and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were coded to accurately reflect immunizations and restraint use. This affected two (Residents #11 and #20) of 24 sampled residents. The facility census was 69 residents.Findings include:1.Review of the medical record for Resident #11 revealed an admission date of 02/14/25 with diagnoses including dementia, mood disorder, and anxiety disorder. Review of the physician's orders for Resident #11 revealed an order dated 09/26/25 for bilateral handrails to promote bed mobility due to weakness. Check placement every shift. Review of the Minimum Data Set (MDS) assessment section P for Resident #11 dated 02/24/26 revealed bed rails were coded as a physical restraint which was used daily. Review of the care plan for Resident #11 revealed it did not include documentation of restraint use for the resident. Review of the medical record for Resident #11 revealed it did not include a restraint assessment. Observation on 03/23/26 at 1:12 P.M. revealed Resident #11's bed had two small handrails attached to each side of the top of the resident's bed to utilize for bed mobility. The handrails did not inhibit the resident's movement in or out of the bed or otherwise restrain the resident. 2. Review of the medical record for Resident #20 revealed an admission date of 12/17/24 with diagnoses including Wernicke's encephalopathy, psychotic disorder with hallucinations, and dementia. Review of the vaccine consent form for Resident #20 dated 09/29/25 revealed the resident was offered and declined the pneumonia vaccine. Review of the MDS assessment for Resident #20 dated 12/22/25 revealed the resident was not up to date with the pneumonia vaccine due to the vaccine not being offered. Interview on 03/26/26 at 9:55 A.M. with Assistant Director of Nursing (ADON) #490 and MDS Nurse #514 on confirmed Resident #11 had handrails ordered for mobility purposes which were not assessed to restrain the resident and the MDS assessment dated [DATE] had been coded inaccurately. ADON #490 and MDS #514 additionally confirmed Resident #20 had been offered the pneumonia vaccine on 09/29/25 and had declined the vaccine and the MDS assessment dated [DATE] had been coded inaccurately.

Based on medical record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASARRs) were completed and updated to reflect new qualifying diagnoses. This affected one (Resident #66) of four residents reviewed for PASARR accuracy. The facility census was 69 residents. Findings include: Review of the medical record for Resident #66 revealed an admission date of 05/14/23 with diagnoses including diabetes mellitus type two, depression, and mood disorders, and osteomyelitis. Review of the most recent PASARR for Resident #66 dated 06/08/23 revealed it did not include a diagnosis of bipolar disorder type two. Review of the diagnosis list for Resident #66 revealed a new mental health diagnosis of bipolar disorder type two was added on 08/20/25. Review of the Minimum Data Set (MDS) assessment for Resident #66 dated 01/12/26 revealed the resident had moderately impaired cognition. Interview on 03/25/26 at 11:43 A.M. with Corporate Director of Nursing #99 verified the facility had not completed a new PASARR for Resident #66 following the addition on 08/20/25 of a new mental health diagnosis for the resident.

Based on medical record review and staff interview, the facility failed to develop a plan of care for residents who received oxygen on a continuous basis. This affected one (Resident #66) of 21 residents reviewed for care plans. The facility census was 69 residents.Findings include: Review of the medical record for Resident #66 revealed an admission date of 05/14/23 with diagnoses including diabetes mellitus type two, depression, and mood disorders, and osteomyelitis. Review of the Minimum Data Set (MDS) assessment for Resident #66 dated 01/12/26 revealed the resident had moderately impaired cognition. Review of the care plan for Resident #66 last revised on 03/07/26 revealed there was no care plan to address the resident's care needs related to supplemental oxygen and oxygen use. Review of the physician's orders for Resident #66 revealed an order dated 03/09/26 for oxygen at two to three liters per minute per nasal cannula to maintain oxygen saturation levels above 90 percent (%) every day and night shift. Interview on 03/25/26 at 11:43 A.M. with Corporate Director of Nursing (DON) #99 verified the facility did not develop a care plan to address Resident #66's care needs related to supplemental oxygen and oxygen use.

Based on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff provided timely bathing and hair washing assistance for dependent residents. This affected one (Resident #8) of the three residents reviewed for activities of daily living (ADL) assistance. The facility census was 69 residents. Findings include:Review of the medical record for Resident #8 revealed an admission date of 11/27/25 with diagnoses including acute kidney failure, adult failure to thrive, and depression. Review of the Minimum Data Set (MDS) assessment for Resident #8 dated 11/27/25 revealed the resident was cognitively intact. Review of the care plan for Resident #8 dated 12/11/25 revealed the resident was at risk for a self-care deficit with bathing, dressing, and feeding. Interventions included the following: encourage the resident to participate in planning day to day care, evaluate the resident's ability to perform self-care, minimize environmental stimuli, provide assistance with ADLs as needed. Review of the shower task list for Resident #8 initiated 11/27/25 revealed the resident was scheduled to receive showers on night shift on Sundays and Thursdays. Review of the shower documentation for Resident #8 dated 02/26/26 through 03/25/26 revealed the resident received showers on 03/06/26 and 03/22/26. There were no additional showers documented during the 30-day time frame. Observation on 03/24/26 at 8:45 A.M. of Resident #8 revealed the resident's hair was greasy and appeared unwashed. Interview on 03/24/26 at 8:46 A.M. with Resident #8 confirmed she preferred to have a shower or bed bath at least twice a week and to have her hair washed on those days. Resident #8 confirmed she had not had her hair washed in weeks and did not receive a shower or bed bath at least twice a week per her preference. Observation on 03/26/26 at 9:05 A.M. of Resident #8 revealed the resident's hair was greasy and appeared unwashed. Interview on 03/26/26 at 9:06 A.M. with Resident #8 confirmed she had still not received a shower or had her hair washed. Interview 03/26/26 at 10:50 A.M. with the Director of Nursing (DON) confirmed residents should receive showers and hair washing per their scheduled preference and staff were to document the showers and care in the resident's medical record. The DON confirmed Resident #8 was documented to have received two showers or bed baths from 02/26/26 through 03/25/26 and was not documented to have refused any care. Review of the facility policy titled Supporting Activities of Daily Living revised March 2018 revealed residents who were unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. This deficiency represents noncompliance investigated under Complaint Number 2647177.

Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure staff obtained resident weights as ordered by the physician. This affected one (Resident #12) of five residents reviewed for nutrition. The facility census was 69 residents.Findings include:Review of the medical record for Resident #12 revealed an admission date of 02/02/26 with diagnoses including adult failure to thrive, chronic obstructive pulmonary disease (COPD), and protein calorie malnutrition. Review of the physician's orders for Resident #12 revealed an order dated 02/02/26 for the resident to be weighed every Monday, Wednesday, and Friday at 6 A.M. due to COPD. Review of the Minimum Data Set (MDS) assessment for Resident #12 dated 02/11/26 revealed the resident had severely impaired cognition. Review of the weight record for Resident #12 dated February 2026 and March 2026 revealed weights were not documented on the following dates: 02/06/26, 02/09/26, 02/11/26, 02/16/26, 02/18/26, 02/20/26, 02/23/26, 02/25/26, 03/02/26, 03/04/26, 03/09/26, 03/11/26, 03/13/26, 03/16/26, 03/18/26, 03/23/26. There was no documentation of resident refusal of weights. Interview on 03/26/26 at 10:30 A.M with the Director of Nursing (DON) confirmed Resident #12 had a physician's order to be weighed every Monday, Wednesday, and Friday at 6:00 A.M. due to COPD. The DON confirmed the facility had no documented weights or refusals of weights for the following dates in February 2026 and March 2026: 02/06/26, 02/09/26, 02/11/26, 02/16/26, 02/18/26, 02/20/26, 02/23/26, 02/25/26, 03/02/26, 03/04/26, 03/09/26, 03/11/26, 03/13/26, 03/16/26, 03/18/26, 03/23/26 Review of the facility policy titled Weights Policy and Procedure undated revealed the facility staff would weigh all residents upon admission and weekly for four weeks and then monthly after admission unless specific diagnoses indicated a daily weight. Additional weights might be requested by the dietitian, physician or nursing staff as needed. All resident weights should be recorded in the weight/vital section of the electronic medical record.

Based on medical record review, staff interview, resident interview, and review of facility policy, the facility failed to ensure staff routinely monitored resident pain levels. This affected one (Resident #20) of five residents reviewed for unnecessary medications. The facility census was 69 residents.Findings include:Review of the medical record for Resident #20 revealed an admission date of 12/17/24 with diagnoses including Wernicke's encephalopathy, psychotic disorder with hallucinations, and dementia. Review of the care plan for Resident #20 dated 05/15/25 revealed the resident was at risk for pain/discomfort. Interventions included the following: administer medications as ordered/as warranted, monitor for effectiveness, assess the resident's pain/location/duration/frequency/intensity and document negative findings. Review of the physician's orders for Resident #20 revealed an order 07/23/25 for Tylenol two 325 milligram (mg) tablets every six hours for left hip pain. Review of the Minimum Data Set (MDS) assessment for Resident #20 dated 12/22/25 revealed was cognitively intact and had occasional pain which made it hard to sleep during five days of the review period. Review of the Medication Administration Records (MARs) for Resident #20 dated February 2026 and March 2026 revealed there was no order for routine pain monitoring and there was no documentation of pain assessment since 02/25/26. Interview on 03/24/26 at 1:50 P.M. with the Director of Nursing (DON) confirmed all residents should have a set day when their pain assessment was to be completed. The DON confirmed Resident #20's medical record did not include a physician's order for routine pain monitoring and the resident's MARS dated February 2026 and March 2026 had no documented pain assessment since 02/25/26. Interview on 03/26/26 at 9:22 A.M. with Resident #20 confirmed his pain level fluctuated but was manageable, and he received scheduled medication for pain which was typically effective. Review of the facility policy titled Pain Management and Assessments undated, revealed all residents would be monitored for pain every shift by nursing and this information should be tracked on the pain section of the resident's MAR flow sheet.

Based on observation, interview, and facilities policy review, the facility failed to follow hand sanitation infection control practices during meal tray delivery. This had the potential to affect seven rooms of residents (Residents in rooms #204, #205, #209, #210, #105, #106 and #110). The facility total census was 64. Findings include: Observation on 03/20/24 during lunch meal tray delivery, between 11:40 A.M. and 11:54 A.M., revealed State tested Nurse Aide, (STNA) # 118 delivered the lunch meal tray to Resident room [ROOM NUMBER]. STNA #118 hands touched resident personal items on the overbed table to make room for the meal tray. The STNA #118 removed lids from the bowls of foods, touched the surface of the overbed table and touched the surface of the resident bed. STNA #118 exited Resident room [ROOM NUMBER] room past a wall mounted hand sanitizer dispensing station and a handwashing sink without sanitizing her hands. STNA #118 returned to the food delivery cart, touched the cart surface, touched her hair and delivered Resident room [ROOM NUMBER] meal tray. STNA #118 was observed to remove resident personal items from the overbed table, remove food container lids and touch the overbed table surface. STNA #118 exited Resident room [ROOM NUMBER] room, past a wall mounted hand sanitizer dispensing station and a handwashing sink, without sanitizing her hands. Observation on 03/20/24 between 11:40 A.M. and 11:54 A.M., revealed STNA #107 entered Resident Rooms #209, arranged personal items on the bedside stand, removed food bowl lids and touched the bed surface. STNA #107 exited Resident room [ROOM NUMBER] room, past a wall mounted hand sanitizer dispensing station and a handwashing sink, without sanitizing her hands. STNA #107 obtained and delivered Resident room [ROOM NUMBER] meal tray without performing hand sanitation between Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER] meal tray deliveries. Observation on 03/20/24 during lunch meal tray delivery, between 11:50 A.M. and 12:01 P.M., revealed STNA #170 delivered the lunch meal tray to Resident room [ROOM NUMBER]. STNA #170 was observed to remove personal items from the overbed table, remove food bowl lids, assisted resident positioning, and touched the bed linens. The STNA #170 exited the room without hand sanitation, including washing or use of hand sanitizer. STNA #170 obtained Resident room [ROOM NUMBER] meal tray and delivered the meal tray. STNA #170 touched personal resident objects on the overbed table. STNA #170 did not perform hand sanitizing when leaving the room. STNA #170 obtained and delivered Resident room [ROOM NUMBER] meal tray with hand sanitizing from meal tray delivery of Resident room [ROOM NUMBER]. Interview on 03/20/24 at 11:48 A.M., STNA #118 verified she had not performed hand sanitation between meal tray delivery of Resident Rooms #204 and Resident room [ROOM NUMBER]. STNA #118 stated hand sanitation should be performed between every meal tray delivery. STNA #118 verified there were hand washing sinks and wall mounted hand sanitizing solution dispensers in every resident room. Interview on 03/20/24 at 11:49 A.M., STNA #107 verified she had not performed hand sanitation between meal deliveries of Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER]. STNA #107 stated sometimes the nurse aides forget to perform hand sanitizing between each meal tray delivery. Interview on 03/20/24 at 12:12 P.M., STNA #170 verified she had not performed hand sanitizing between meal tray delivery between Resident Rooms #105, Resident room [ROOM NUMBER] and Resident room [ROOM NUMBER]. STNA #170 stated she was unsure how often hand sanitation should occur between meal tray deliveries. Interview on 03/21/24 at 10:39 A.M. the Director of Nursing, (DON) verified hand sanitizing should occur after handling a resident's belongings. The DON verified hand sanitizer solution and hand washing sinks were in each resident room for staff to perform hand sanitizing after meal tray delivery and prior to delivery of the next resident's meal delivery. Review of the facility policy, titled, Infection Control Hand Hygiene, undated, revealed hand hygiene is in reference to utilization of alcohol-based products and or hand washing with soap and water. Use of hand hygiene is required before and after every resident contact including touching a resident, handling the resident's belongings, and after touching the face or hair.

Based on record reviews and staff interview, the facility failed to ensure Preadmission Screening and Resident Review (PASRR) was completed accurately and following the additional of a new mental health diagnosis. This affected three residents (#6, #39, and #53) out of the four residents whose PASRR's were reviewed during the annual survey. The facility census was 64. Findings include: 1. Record review for Resident #6 revealed the resident was admitted to the facility on [DATE] and had diagnoses including dementia without behavioral disturbance, psychotic disturbance, and mood disturbance. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/20/24, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 05 out of 15. Further record review for Resident #6 revealed the resident had a new mental health diagnosis of psychosis added on 01/04/21 while residing in the facility. No new PASRR was completed following the addition of a new mental health diagnosis. Interview with the Administrator on 03/20/24 at 11:30 A.M. confirmed a new PASRR was not completed following the addition of the diagnosis of psychosis on 01/04/21. 2. Record review of Resident #39 revealed the resident was admitted to the facility on [DATE] and readmitted [DATE]. Diagnoses for Resident #39 included diagnosis of depression listed on 10/10/23, psychosis listed on 05/05/22, and anxiety disorder listed on 06/08/21. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed, the resident had impaired cognition and was receiving medications Duloxetine HCL 20 milligrams (mg) at bedtime for depression and Buspirone HCL 10 mg two times a day for anxiety disorder. Review of Resident #39 PASARR , dated 09/13/22, did not include the diagnoses of psychosis and depression. Interview on 03/20/24 at 2:30 P.M. the Administrator verified Resident #39 PASARR, dated 09/13/22, was inaccurate as it did not include the resident's diagnoses of psychosis and depression. 3. Record review of Resident #53 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #53 included dementia, bipolar disorder and depression. Review of the Minimum Data Set, (MDS) comprehensive assessment dated [DATE], revealed the resident had severely impaired cognition and was receiving medications Olanzapine 2.5 mg two times a day for bipolar disorder, Divalproex sodium 125 mg for bipolar disorder and Citalopram hydrobromide 10 mg for depression. Review of Resident #53 PASARR , dated 02/02/22, did not include the diagnoses of bipolar disorder and dementia. Interview on 03/20/24 at 2:30 P.M., the Administrator verified Resident #53 PASARR, dated 02/02/22 was inaccurate as it did not include the resident's diagnoses of bipolar disorder and dementia.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the hospital discharge summary, review of the fall investigation, staff interview, and review of the facility policy, the facility failed to provide Resident #64 with a safe transfer using a mechanical lift. Actual Harm occurred to Resident #64 on 10/25/22 when the resident received assistance from two staff persons using a mechanical lift without staff first securing the loop of the lift pad correctly resulting in an avoidable fall with injuries including unspecified fracture of the shaft of the right and left tibia and fibula. This affected one (Resident #64) of three residents reviewed for falls. The facility census was 64. Findings include: Review of the medical record revealed Resident #64 was readmitted to the facility from an acute hospital stay on 10/26/22 with diagnoses including unspecified fracture of the shaft of the right and left tibia and fibula, quadriplegia, and hypertension. Review of the fall risk assessment dated [DATE] revealed Resident #64 was not at risk for falls. Review of the fall risk assessment dated [DATE] revealed Resident #64 was at high risk for falls. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was alert and oriented to person, place and time. Resident #64 was identified as needing total dependence on two staff persons for transfers using a mechanical lift. Review of the plan of care dated 11/04/22 revealed Resident #64 was at a risk for falls due to decreased mobility, recent (inoperable) bilateral tibia/fibula fracture, quadriplegia, weakness, decreased mobility, non ambulatory, and required a Hoyer lift for transfers. Interventions included keep call light in reach, pathways free of clutter, two person assist with transfers using a Hoyer lift, night light in bathroom, encourage resident to participate in care and may get up per Hoyer lift to wheelchair with foot extenders with immobilizers in place to bilateral lower extremities. The plan of care also revealed Resident #64 had a self-care deficit as evidenced by recent (inoperable) bilateral tibia and fibula fractures, quadriplegia, weakness, decreased endurance and impaired balance. The resident was non ambulatory. Interventions included weight bearing support of one to two staff for bed mobility, dressing, toileting, hygiene and bathing and total dependence on two staff persons using a mechanical lift for transfers. Review of the facility fall investigation dated 10/25/22 revealed Resident #64 was being transferred via Hoyer lift with two State tested Nursing Assistants (STNA) using the appropriate mechanical lift sling. One STNA attached the upper left and right loops of the sling while the other STNA attached the lower left and right loops. The facility conclusion indicated the metal safety clip, which would secure the left shoulder strap/loop onto the hook was not engaged. The loop instead was rested on the tip of the hook. Resident #64 was elevated into the air to transfer when she began to wiggle and move attempting to reposition herself in the lift sling. During these movements the loop on the left shoulder strap of the lift sling dislodged resulting in the resident falling to the floor rapidly resulting in bilateral tibia and fibula fractures. Review of the nurse's note dated 10/25/22 at 12:45 A.M. revealed the nurse responded to calls from resident's room to find Resident #64 lying on her back with her left leg lying over the Hoyer lift leg and the right leg bent at the knee behind the leg. The STNA's reported the resident fell out of the top of the Hoyer lift sling during transfer from wheelchair to bed. Resident #64 complained of pain at level 10 out of 10 and was sent to the local emergency room for evaluation and treatment. A nurse's note dated 10/26/22 at 4:25 P.M. revealed the resident returned to the facility at approximately 11:30 A.M. with immobilizers in place to bilateral lower extremities. Review of the hospital discharge summary dated 10/26/22 at 12:45 P.M. revealed the resident was seen in the emergency department after a fall at the nursing home. The orthopedic team at the hospital saw Resident #64 related to fracture in both of her legs. The orthopedic team believed the fractures would heal without any need for surgery. During the emergency room visit the resident had imaging tests completed. The x-rays of the right and left lower extremity indicated minimally displaced proximal tibial metaphyseal fracture and nondisplaced proximal fibular fracture of the left leg. The x-rays indicated mildly displaced comminuted proximal fibular and tibial metaphyseal fracture to the right leg. An interview on 02/06/23 at 10:00 A.M. with the Director of Nursing (DON) confirmed Resident #64 fell from the Hoyer lift sling while being transferred from wheelchair to bed resulting in fractures to bilateral tibia and fibulas. The DON stated the sling came out of the hook on the lift bar and the security clip was not in place. Review of the facility's policy titled Hoyer Lift Policy and Operation revealed it is the policy of this facility to provide safe transfers for all residents that are unable to transfer themselves. The method of transfer will be decided by the Interdisciplianry Team and addressed in the resident's plan of care. The deficient practice was corrected on 11/11/22, when the nurse managers provided education on the Hoyer lift sling safety checks and the policy and procedure of Hoyer lift operation to 25 nurses and 40 STNAs, and the facility implemented the following corrective actions: On 10/25/22, Resident #64 was sent to the local emergency department for evaluation and treatment. On 10/25/22, the Director of Patient Services inspected the residents Hoyer lift. The lift was in clean condition and showed minor wear marks on areas of movement. There were no cracks or broken areas to the main structure. All of the bolts were in place and tight. There were a total of six sling clips on the boom and all were operational and in working order. The base extended smoothly with no jerking motions and worked well with the no issues. The boom rose and fell smoothly, all four wheels moved freely and locks operated with no issues. On 10/25/22, the DON provided education on Hoyer lift sling safety checks and policy and procedure of Hoyer lift operation to the two STNA's involved in the incident. On 10/25/22 through 11/11/22, the nurse managers provided education on Hoyer lift sling safety checks and policy and procedure of Hoyer lift operation to 25 nurses and 40 STNA's. On 10/25/22 and ongoing, the nurse managers completed competency checks on how to use the Hoyer lift correctly and safely with the nurses and STNA's. On 10/25/22, the DON provided education to the laundry staff regarding how to correctly wash and inspect the Hoyer lift slings. On 10/25/22, the DON and nurse managers numbered the mechanical lifts and corresponding lift pads. On 10/25/22, Resident #64's plan of care was updated. Beginning 10/25/22, ongoing audits/observations of lift transfers on lift involved weekly for four weeks, then as determined by Quality Assurance. There were no unsafe resident transfers from 10/25/22 to 02/13/23 the time of the onsite complaint investigation. This deficiency represents non-compliance investigated under Complaint Number OH00140041.

Based on medical record review, observation, and staff interview, the facility failed to maintain dignity while feeding Resident #44. The facility identified two residents who were dependent on staff for feeding. The facility census was 64. Findings include: Review of the medical record of Resident #44 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/15/21, revealed the resident had impaired cognition and was dependent on the assistance of one staff for feeding. Observation and interview on 06/28/21 at 11:43 A.M. revealed Resident #44 laying in bed. The right side of Resident #44's bed was against the wall and RN #139 was standing at the left side of the bed feeding Resident #44. RN #139 verified she was feeding Resident #44 while standing up and further stated she was right-handed so it was easier for her to feed the resident while standing up. Interview on 07/01/21 at 10:00 A.M. with the Director of Nursing (DON) stated the expectation was for staff to be seated when feeding residents.

Based on record review and staff interview, the facility failed to accurately code a resident's fall status on the Minimum Data Set (MDS) assessment. This affected one (Resident #13) of 18 residents reviewed for accurate MDS assessments. The facility census was 64 residents. Findings include: Review of the medical record for Resident #13 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes revealed the resident had falls on 03/04/21, 11/22/20, and 11/07/20. Review of the Minimum Data Set (MDS) assessments revealed a quarterly assessment was completed on 04/05/21, an annual assessment was completed on 02/11/21, and a quarterly assessment on 11/18/20. No additional MDS assessments were completed between 11/18/20 and 04/05/21. Subsequent review of the MDS assessments, dated 04/05/21 and 02/11/21, revealed section J1800 was negative for any falls since the prior assessment. Interview on 06/30/21 at 2:38 P.M. with Licensed Practical Nurse (LPN) #114 verified the MDS assessments for Resident #13, dated 04/05/21 and 02/11/21, were coded incorrectly and should have indicated there was a fall.

Based on record review, observations, and staff interviews, the facility failed to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This affected three residents (Resident #27, #44, and #215) of 23 residents receiving oxygen therapy. The facility census was 64. Findings include: 1. Record review for Resident #27 revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set assessment, dated 05/05/21, revealed the resident was rarely/never understood. Review of the physician orders, dated 06/2021, revealed there were no orders for the use of oxygen. After surveyor intervention on 06/29/21, there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #27 on 06/28/21 at 2:38 P.M. revealed the resident had oxygen tubing that was not labeled or dated during the time of use. Subsequent observation of Resident #27 on 06/29/21 at 2:35 P.M. revealed the oxygen tubing was still not labeled or dated. During this observation, Registered Nurse (RN) #212 verified the oxygen was running at three liters per minute and tubing was unlabeled or dated. The RN explained a contracted provider supplies the oxygen and they change out the tubing weekly, and they do not label or date the tubing. 2. Record review for Resident #215 on 06/29/21 at 1:58 P.M. revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 06/19/21, revealed the resident had intact cognition. Review of the physician orders, dated 06/2021, revealed there were no orders for the use of oxygen. After surveyor intervention on 06/29/21, there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of Resident #215 on 06/28/21 at 3:22 P.M. revealed the resident had oxygen tubing that was not labeled or dated during the time of use. Subsequent observation of Resident #27 on 06/29/21 at 2:35 P.M. revealed the oxygen tubing still not labeled or dated. During the observation, RN #212 verified the oxygen was running at three liters per minute and the tubing was unlabeled or dated. On 06/30/21 at 2:40 P.M., an interview with the Director of Nursing (DON) on 06/30/21 at 2:40 P.M. verified Resident #27 and #215 did not have an active order for oxygen in place until it was obtained on 06/29/21. The DON verified the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of the medical record for Resident #44 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment, dated 06/15/21, revealed the resident had impaired cognition. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the treatment administration record (TAR) revealed RN #139 signed off the oxygen as administered on 06/28/21 and 06/29/21. Observations on 06/28/21 at 9:42 A.M. and 11:43 A.M, and on 06/29/21 at 3:00 P.M., and 4:08 P.M. revealed no oxygen concentrator nor oxygen tank in Resident #44's room. Observation on 06/29/21 at 3:00 P.M. revealed a nebulizer placed on Resident #44's bedside table. The tubing did not contain any date to indicate when it was last replaced. Interview on 06/29/21 at 4:08 P.M. with RN #139 verified there was no there was no date on the nebulizer tubing nor were there oxygen concentrator or tanks in Resident #44's room. The RN further stated Resident #44 had not received oxygen anytime recently. RN #139 verified the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review, observation, and staff interview, the facility failed to ensure the resident's call lights were functioning. This affected three (Resident #09, #16 and #18) of 24 residents reviewed for call lights. The facility census was 64 residents. Findings include: 1. Review of the medical record of Resident #09 revealed an admitted [DATE]. Diagnoses included dementia without behavioral disturbance, type 2 diabetes mellitus, muscle weakness, and [CONDITION(S)]. Review of the Medicare five-day Minimum Data Set (MDS) assessment, dated 06/23/21, revealed the resident had impaired cognition and required extensive assistance of two staff for bed mobility, transfers, and toileting. Review of the medical record for Resident #18 revealed an admitted [DATE]. Diagnoses included [CONDITION(S)] disease, acute ischemic heart disease, dementia with behavioral disturbance, and cerebral infarction (stroke). Review of the comprehensive MDS assessment, dated 04/14/21, revealed the resident had impaired cognition, required extensive assistance of two staff for bed mobility and extensive assistance of one staff for transfers and toileting. Observation on 06/28/21 at 11:28 A.M. revealed Resident #09's call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door. Observation on 06/28/21 at 11:29 A.M. revealed Resident #18's (Resident #09's roommate) call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door. Interview on 06/28/21 at 11:35 A.M. with Registered Nurse (RN) #215 verified the light did not light up outside the room of Residents #09 and #18 and did not transmit a signal to the pagers carried by the staff. 2. Review of the medical record for Resident #16 revealed an admitted [DATE]. Diagnoses included chronic obstructive pulmonary disease, dementia with behavioral disturbance, anxiety disorder, major depressive disorder, and non-st elevation (NSTEMI) [CONDITION(S)] infarction. Review of the quarterly MDS assessment revealed the resident had intact cognition and required supervision for bed mobility, transfers, and ambulation. Observation on 06/28/21 at 2:20 P.M. revealed Resident #16's call light was activated via the call button at the resident's bedside. The light was not observed to turn on outside of the room above the door. Interview on 06/28/21 at 2:20 P.M. with State tested Nursing Aide (STNA) #240 verified the light did not come on outside the door nor did not transmit a signal to the pagers carried by the staff. Further interview with STNA #240 revealed the call light cord was not plugged into the wall.

Based on medical record review, observations, staff interview, and review of facility policy, the facility failed to ensure a resident was free from a physical restraint. This affected one resident (#64) of one resident reviewed for physical restraints. The facility census was 73. Findings include: Medical record review revealed Resident #64 was admitted to the facility on [DATE] with the following diagnoses; cerebral infarction (stroke), major [MEDICAL CONDITION], cognitive communication deficit, [MEDICAL CONDITIONS], and anxiety disorder. Review of Resident #64's quarterly Minimum Data Set (MDSs) assessment dated [DATE] revealed the resident had severe cognitive impairment. The MDS further revealed the resident was totally dependent on staff with transfers and had a chair alarm. Review of Resident #64's care plan revealed the resident had a self releasing alarm seat belt in place on her wheelchair. The care plan identified Resident #64's seat belt as an enabler due to it enabling her to maintain an appropriate position in her wheelchair. The care plan further revealed Resident #64 was able to release her seat belt on her own. Review of Resident #64's physical restraint assessment dated [DATE] revealed the resident leaned to the right, had poor trunk control, was unable to recover the loss of balance when sitting and was unable to stand except with weight bearing support of two staff. Resident #64 demonstrated the ability to release and reapply the Velcro self releasing alarming seatbelt every time upon request, therefore the seat belt was not considered a restraint. Review of Resident #64's progress note dated 03/04/19 revealed an interdisciplinary team meeting was held on 02/28/19. Resident #64's self releasing alarm seat belt was in use to increase resident's sense of safety. Resident #64 was reported to be recently observed fastening and unfastening her seatbelt at random times. The note also revealed the seat belt did not restrain the resident from exiting the chair. Observation of Resident #64 on 03/14/19 at 9:03 A.M., revealed resident to be sitting in her wheelchair in the dining room with her Velcro self releasing alarming seat belt in place. Observation of Resident #64 on 03/14/19 at 9:11 A.M., revealed Registered Nurse (RN) #124 asked Resident #64 to take off her Velcro self releasing alarming seat belt. RN #124 asked the resident several times and cued her by pointing to the seat belt connector. Resident #64 stared at RN #124 and after being cued multiple times she was able to slightly lift up the plastic clip to her seat belt setting off the alarm. Resident #64's seat belt was remained fastened with the Velcro. RN #124 verified Resident #64 was able to lift the plastic clip on her seat belt after being cued multiple times, however the seat belt remained fastened with the Velcro. RN #124 revealed the resident became agitated at times when attempting to remove the seat belt. Review of the facility's Physical Restraints policy dated 01/08/12 revealed physical restraints to be any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot easily remove which restricts freedom of movement or normal access to one's own body.

Based on medical record review, staff interview, and facility policy review, the facility failed to implement their abuse policy when they failed to submit a self-reported incident (SRI) to the state agency regarding a resident to resident physical abuse, and further failed to ensure a resident was free from resident to resident physical abuse. This affected one resident (#12) of one resident reviewed for abuse. The facility census was 73. Findings include: 1. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with the following diagnoses; unspecified dementia with behavioral disturbance, anxiety disorder, unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition, and major [MEDICAL CONDITION]. Review of Resident #12's annual Minimum Data Sets (MDSs) assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #12's progress note written by Registered Nurse (RN) #124 dated 12/19/18 revealed Resident #12 said a man came in and grabbed her wrist and knocked her stuff off of her door. Resident #12 was noted with a small skin tear and a bruise. Both residents were separated. Resident #12 was ordered a treatment for [REDACTED]. 2. Medical record review revealed Resident #220 was admitted to the facility on [DATE] with the following diagnoses; transient cerebral ischemia attack (stroke), unspecified [MEDICAL CONDITION] not due to substance or known physiological condition, [MEDICAL CONDITION], and major [MEDICAL CONDITION]. Resident #220 passed away at the facility on 01/20/19. Review of the resident MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. Review of Resident #220's progress note written by RN #124 dated 12/19/18 revealed a State tested Nurse Aide (STNA) reported Resident #12 said Resident #220 came in her room, knocked decorations off her door and grabbed her wrist causing a skin tear with a small bruise. Both residents were separated and placed on 15 minute checks. Review of the Activities Director (AD) #14's statement dated 12/19/18 revealed the AD was walking down the hallway and witnessed Resident #220 at Resident #12's doorway pulling at her decorations. Resident #12 approached Resident #220 at the same time and Resident #220 reached out and grabbed Resident #12's wrist. AD #14 intervened and redirected Resident #220 away from the doorway. Interview with the Director of Nursing (DON) on 03/13/19 at 12:57 P.M., verified Resident #220 grabbed Resident #12 causing a bruise and an skin tear on 12/19/18. The DON revealed she investigated the incident and found Resident #220 was knocking down Resident #12's decorations and grabbed Resident #12's arm and his finger nail caught her arm leaving a skin tear. The DON confirmed a SRI was not completed and submitted regarding the resident to resident physical abuse between Resident #12 and Resident #220. Review of the facility's Abuse and Neglect policy dated (MONTH) (YEAR) revealed abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment that results in physical harm, or pain or mental anguish. All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of property, are reported immediately, but not later than two hours after the allegation is made if the events that cause the allegation involve abuse or result in seriously bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse or do not result in serious bodily injury.

Based on observation, record review and staff interview the facility failed to ensure assistive devices were in place to prevent an avoidable fall with injury. This affected one resident (#6) of four reviewed for falls. This resulted in harm for Resident #6 who fell out of bed fracturing her right femur which required surgery and subsequent hospitalization . The facility census was 70. Findings include: Review of the medical record for Resident #6 revealed an admitted on 04/26/10 with a readmitted on 12/12/13 after a brief hospitalization for repair of a fractured femur. Pertinent [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident was rarely or never understood. The resident required extensive assistance of two people for bed mobility, transfer, dressing and toilet use. The resident used a wheelchair and walker to aid in mobility and was not steady when moving from a seated to standing position and could only stabilize with staff assistance. Review of the fall assessment prevention and management care plan updated 10/17/13 revealed interventions included bed alarm sensor. The point of care nurse aide documentation dated 12/07/13 revealed the bed alarm sensor was utilized daily for Resident #6 to alert staff of attempts of getting out of bed. On 12/07/13 at 8:49 P.M., State tested Nursing Assistant (STNA) #14 documented the bed alarm sensor was in place. Review of a fall investigation incident dated 12/07/13 at 10:00 P.M. revealed Registered Nurse (RN) #11 was in the hallway and heard a loud noise. RN #11 went into Resident #6's room and the resident was lying at the foot of her bed on her right side with her knees up to her chest and her head. An immediate golf ball sized hematoma was noted to the right side of her head. The bed sensor pad alarm was not attached and was not sounding. Review of the progress note dated 12/08/13 at 2:16 A.M. revealed the physician was notified of Resident #6 having increase in pain to her right leg and hip. Review of the radiology report dated 12/08/13 revealed Resident #6 had a subtle impaction of the right femoral neck and findings suggested a fracture. Review of the progress notes dated 12/08/13 at 7:03 P.M. revealed X-ray results reported to the physician with new order to send to the hospital emergency room for evaluation of the right femur. Review of the hospital radiology results dated 12/08/13 at 10:01 P.M. revealed an acute subcapital femoral neck fracture. Review of the hospital operative notes dated 12/09/13 at 5:56 P.M. revealed Resident #6 was taken to the operating room and three screws were implanted in the femoral neck to repair the fracture. The progress notes dated 12/13/13 revealed Resident #6 was readmitted to the facility on [DATE]. Review of the personnel file for STNA #12 revealed she received staff education/counseling on 12/09/13 for not verifying alarms were transferred with a resident. STNA #12 indicated in her statement that the alarm was not sounding for Resident #6 after her fall and the bed alarm sensor was not in place. Review of the personnel file for STNA #14 revealed she received staff education/counseling on 12/21/13 for not verifying alarms were transferred with Resident #6 on 12/07/13, the day of her fall. Interview with the Administrator on 07/09/14 at 2:55 P.M. revealed RN #11, STNA #12 and STNA #14 were responsible for providing care for Resident #6 when she had her fall with injury on 12/07/13. Interview with RN #11 on 07/09/14 at 3:40 P.M. revealed Resident #6 did not have her bed alarm sensor pad in place when she fell on [DATE]. RN #11 stated she wrote up STNA #12 and #14 since they were providing care for Resident #6 on 12/07/13 and they failed to ensure the bed alarm sensor was plugged in when they put Resident #6 to bed. Observation and interview with STNA #20 on 07/10/14 at 11:20 A.M. revealed an alarm sensor pad on Resident #6's bed. STNA #20 stated that the alarm sensor pad was normally unplugged and they attach it once they lay Resident #6 down in bed. She further indicated when Resident #6 was in her wheelchair she plays with the alarm. STNA #20 stated that the alarm alerts staff to Resident #6 attempting to get out of bed. Review of Occupational therapy updated plan of treatment dated 02/10/14 revealed that on 12/12/13 Resident #6 was total dependent for bed mobility with attempts to self initiate.