Every finding on record at Care One at Essex Park

Based on records reviewed and interviews, for one of three sampled residents (Resident #1) who was having difficulty moving his/her bowels, the Facility failed to ensure he/she was provided care and treatment in accordance with acceptable standards of practice, when a Certified Nurse Aide (CNA) used her fingers to digitally disimpact (remove harden mass of feces from rectum) Resident #1, which was not within a CNA's scope of practice or job description and per the facility, was not a procedure that CNA's could perform. Findings include:Review of the Facility's Job Description titled, Certified Nursing Assistant, which was provided by the facility indicated it was last updated in 12/2006, identified that essential duties and responsibilities of a Certified Nursing Assistant (CNA) consisted of the following:-Perform all assigned tasks in accordance with the Facility's Policies and Procedures, and as instructed by your supervisors.-Report all resident changes in condition promptly to the Nurse Supervisor/Charge Nurse.-Assist in preparing the resident for a physical examination.-Report all complaints made by the resident to the Nurse Supervisor/Charge Nurse.-Assist resident with bowel and bladder functions (i.e., take to the bathroom, offer bedpan/urinal, portable commode, etc.)-Prepare and give enemas.-Check and report bowel movements and character of stools as instructed.-Record all entries on flow sheets, notes, charts, etc., in an informative and descriptive manner.Further Reviewed of the CNA Job Description indicated that digital disimpaction of a resident was not part of a CNA's job responsibilities.Review of Mass.gov article titled, Massachusetts Certified Nurse Aide (CNA) Curriculum Frameworks, dated released on April 2026, indicated the CNA Scope of Practice and Bowel Management, that CNAs play a vital collaborative role in patient care, but invasive procedures like manual disimpaction are prohibited. The article indicated CNAs provide critical frontline support by the following:-Observing and Documenting: Monitoring for abdominal distension, pain, and the frequency/consistency of bowel movements.-Encouraging Intake: Ensuring residents maintain adequate fluid and fiber intake to prevent hardened stools from forming in the first place.-Positioning and Comfort: Assisting residents to the toilet or commode and applying skin barrier creams if fecal incontinence or irritation occurs.The article indicated the Clinical Risks of Disimpaction Manual (digital) disimpaction requires careful clinical assessment due to the physiological stress it places on the elderly.The article indicated the procedure carries several high-risk complications that necessitate licensed nursing oversight such as the following:- Vagus Nerve Stimulation: Inserting a lubricated finger into the rectal vault can trigger a parasympathetic response, leading to a sudden drop-in heart rate (bradycardia) or dangerous cardiac arrhythmias.-Bowel Trauma: Debilitated elderly residents often have fragile, friable rectal tissue. Forceful removal risks tissue damage, mucosal tearing, or bowel perforationThe article indicated that nursing facilities must establish strict protocols for bowel management, indicating while CNAs may assist with toileting or perineal care, any invasive bowel intervention requires direct experiential training, a specific Physician or Nurse Practitioner Order, and execution by Licensed Staff.Review of the report submitted by the facility via Health Care Facility Reporting System (HCFRs), dated 03/04/26, indicated Resident #1 reported to his/her Health Care Proxy (HCP) that a CNA (exact name unknown) disimpacted him/her during the night over the weekend. The Report indicated Resident #1 was interviewed and Resident #1 said it was painful when the CNA disimpacted him/her.Resident #1 was admitted to the Facility in February 2006 diagnoses included Severe Aortic Stenosis (heart's aortic value becomes heavily narrowed and stiffened, restricting normal blood flow from the heart to the rest of the body), Atrial Fibrillation (irregular heartbeat), Hypertension (high blood pressure), Diabetes and stroke without residual deficits (blood flow to an area of the brain is cut off or a blood vessel bursts).Review of Resident #1's Medical Record indicated he/she had a mild cognitive impairment with some confusion, but was Alert & Oriented x3 (Person, Place and Time), speech was clear and he/she could understand and be understood when speaking. During a telephone interview on 06/02/2026 at 11:54 A.M., the Nursing Supervisor said on 03/01/26 she was assigned to Resident #1. The Nursing Supervisor said Resident #1 requested a medication to help him/her to not become constipated again. The Nursing Supervisor said shortly thereafter, Resident #1's HCP informed her that Resident #1 had informed her (HCP) that a CNA had used her fingers to pull poop out of his/her bum and it hurt when it was being done.The Nursing Supervisor said she went to speak to Resident #1, who restated to her, the same information his/her HCP had shared, which was he/she had been disimpacted by a CNA (exact name unknown). The Nursing Supervisor said Resident #1 denied being in pain at the time of the interview. The Nursing Supervisor said she had physically assessed Resident #1, and no skin issues or areas of trauma were observed.The Nursing Supervisor said she informed the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) of the allegation of a CNA (exact name unknown) disimpacting Resident #1.During an interview on 05/20/2026 at 10:56 A.M., the Assistant Director of Nursing (ADON) said on 03/02/26, the Nursing Supervisor informed her Resident #1 said he/she had been disimpacted by a CNA (later identified as CNA #1). The ADON said on 03/02/26, Resident #1 said on 02/27/26, he/she had been constipated, and the Nurse gave him/her medication to aid with a bowel movement. The ADON said Resident #1 said early in the morning on the overnight shift of Friday 02/27/26 into Saturday 02/28/26, he/she had asked a CNA to help him/her into the bathroom. The ADON said Resident #1 said he/she told the CNA he/she felt like he/she needed to move their bowels but felt like something was stuck in his/her rectum.The ADON said Resident #1 then said that the CNA (CNA #1) did not inform him/her what she was going to do prior and the CNA inserted her finger into his/her rectum to help him/her move their bowels. The ADON said Resident #1 said he/she did not ask CNA to disimpact him/her.During an interview on 05/20/26 at 3:13 P.M., Nurse #1 said he was unaware Resident #1 had been disimpacted by CNA #1 early in the morning on the overnight shift of Friday 02/27/26 into Saturday 02/28/26. Nurse #1 said neither Resident #1 or CNA #1 had not informed him that Resident #1 had been constipated or that CNA #1 had disimpacted Resident #1 during the shift.The Surveyor was unable to interview CNA #1 as she did not respond to the DPH telephone request for an interview.During an interview on 05/20/2026 at 11:48 A.M., the Director of Nursing (DON) said on 03/02/26, Resident #1's HCP informed her that Resident #1 had been disimpacted by a CNA (later identified CNA #1). The DON said on 03/02/26 Resident #1 said he/she was unable to move their bowels, a CNA penetrated him/her with her fingers to remove stool. The DON said Resident #1 said the incident was painful, but he/she felt relief afterwards.The DON said she spoke to CNA #1 by telephone and CNA #1 admitted she had disimpacted Resident #1. The DON said that CNA #1 told her she thought she was helping Resident #1, that she (CNA #1) did not know it was not within her CNA scope of practice. The DON said CNA #1 said she was unaware that the Facility does not allow Nurses and/or CNAs to disimpact residents. The DON said CNA #1 was terminated.The DON said it was Facility's Policy that Nurse's and CNAs are not to perform manual digital disimpaction of residents and that nursing is to notify the Physician if there is an issue.

Based on record review and interview the facility failed to provide care and services consistent with professional standards of practice for one Resident (#11) with a pressure ulcer, out of a total sample of 35 Residents. Specifically, for Resident #11 the facility failed to implement wound treatment recommendations from the consulting wound physician. Findings include: Resident #11 was admitted to the facility in June 2025 with diagnoses that included muscle weakness, type 2 diabetes and dementia. Review of the Minimum Data Set (MDS) assessment, dated 1/1/26, indicated a Brief Interview for Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident had one or more unhealed pressure ulcers, including one stage 4 pressure ulcer that was present on admission to the facility. Review of the most recent Norton Assessment (an assessment to assess a resident's risk for skin breakdown and the development of pressure ulcers), completed 7/23/25, indicated a risk score of 8 indicating high risk for pressure ulcer development. Review of the active skin care plan, dated 3/4/26, that indicated the following:-Actual skin breakdown related to pressure ulcer- Left Ankle.-Interventions included: wound consult as needed and follow-up care with physician as ordered. Review of the Wound Consultant Notes, dated 3/17/26, 3/24/26 and 3/31/26 indicted the following recommendation for the treatment of a stage 4 pressure wound to the left, lateral ankle full thickness wound:-Dressing treatment plan: Primary Dressing(s) Collagen sheet w/silver apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days: Apply on wound base; Alginate calcium, apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days Secondary Dressing(s) Tubi-grip apply once daily and as needed: if saturated, soiled, or dislodged. For 23 days; Foam, apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days Review of active physician's orders, dated 2/10/26, indicated the following:-Left lateral ankle pressure injury POA (present on arrival): cleanse w/ NS (normal saline), pat dry, apply skin-prep to intact peri-wound skin, apply Anasept soaked gauze, boarder foam, wrap with ACE bandage daily and as needed. May use silver hydrogel if waiting for Anasept to be delivered. Review of the March 2026 Treatment Administration Record (TAR) indicated that the active order, dated 2/10/26, as listed above was implemented every day in March. Review of the medical record failed to indicate that when the treatment recommendation was changed on 3/17/26, it was implemented into the Resident's plan of care. During an interview on 4/1/26 at 12:44 P.M., Nurse #1 said that when a consulting provider sees residents on the unit, they will report off to the nurses or unit manager at the end of rounding. She said that if they were making any changes, they will let the staff know, but they also upload their consult note into the electronic medical record (EMR) for review. She said that they would call the primary providers to confirm orders and implement them. During an interview on 4/1/26 at 1:10 P.M., Unit Manager #1 said that a nurse rounded with the consulting wound physician and provided any newly recommended treatments to the Unit Managers. She said the Unit Managers consulted with the facility providers and implemented the recommendations. She said that the facility providers generally did not go against the wound physician's recommendation and implement any changes that were recommended. The Unit Manger and the surveyor reviewed the recommendations and the medical record, and she said that Resident #11's recommendations should have been implemented immediately following the change in treatment plan on 3/17/26 but they were not. During an interview on 4/1/26 at 2:23 P.M., the Director of Nurses said that the Assistant Director of Nurses rounded with the consulting wound physician generally. She said the wound physician lets her know any changes that will be recommended to the plan of care. She said the wound consultant's note is uploaded into the EMR where it is reviewed by facility staff, and changes should be implemented as indicated.

Based on record review and interviews, the facility failed to ensure that medications were accurately implemented by nursing for one Resident (#11), out of a total sample of 35 residents, to ensure he/she was free from a significant medication error. Specifically, the facility failed to accurately implement a medication recommendation from Behavioral Health Services. Findings include:Resident #11 was admitted to the facility in June 2025 with diagnoses that included anxiety, insomnia and dementia. Review of the Minimum Data Set (MDS) assessment, dated 1/1/26, indicated a Brief Interview for Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. The MDS failed to indicate any behaviors were present during the look back period. The MDS further indicated that the Resident received antidepressant medications. Review of the Behavioral Health Note, dated 2/20/26, indicated the following:-Plan/ Recommendations:-Increase the Trazodone (antidepressant medication) to 50 mg HS (milligrams at bedtime) for insomnia.-Continue to monitor his/her mood & behavior. -Provide structured daily routine & maintain sleep routine. Review of active physician's orders, as of 4/1/26, indicated the following:-Trazodone tablet, give 25 mg by mouth in the morning for anxiety AND Give 25 mg by mouth at bedtime for insomnia give with 50mg = 75mg AND Give 50 mg by mouth at bedtime for insomnia give with 25mg = 75mg AND Give 25 mg by mouth every 12 hours as needed for agitation for 14 Days, dated 3/4/26. Review of discontinued physician orders indicate the following:-Trazodone 50 mg at bedtime (8:00 P.M), active from 2/20/26 to 3/3/26. -Trazodone 25 mg by mouth one time a day (at 8:00 P.M.) for insomnia, active from 6/7/25 to 3/3/26.-Trazodone 25 mg one time a day (at 9:00 A.M.) for anxiety disorder, active from 9/2/25 to 3/3/26. Review of the February and March 2026 Medication Administration Record (MAR) indicated that the Resident received Trazodone 75 mg at bedtime from 2/2/26 through 3/31/26. During an interview on 4/1/26 at 12:44 P.M., Nurse #1 said that when a consulting provider sees residents on the unit, they will report off to the nurses or unit manager at the end of rounding. She said that if they are making any changes, they will let the staff know, but they also upload their consult note into the electronic medical record (EMR) for review. She said that they will call the primary providers to confirm orders and implement them. During an interview on 4/1/26 at 12:57 P.M., Unit Manager #1 reviewed the medical record and the behavioral health recommendation with the surveyor. She said that a transcription error had occurred resulting in a medication error because the Resident had been receiving 75 mg of trazodone at bedtime instead of the recommended 50 mg. She said that the facility does not currently have a process for anyone to double check and ensure that orders have been entered or transcribed correctly. During an interview on 4/1/26 at 2:19 P.M., the Director of Nurses said the recommendation was not implemented correctly resulting in a medication error.

Based on record reviews and interviews, the facility failed to ensure one Resident (#14) was free from unnecessary antipsychotic medications by ensuring the psychiatric Nurse Practitioner recommendations for a gradual dose reduction (GDR) were communicated to the Resident's physician, out of a total sample of 35 residents. Findings include:Resident #14 was readmitted to the facility in January 2026 with diagnoses that included Post Traumatic Stress Disorder, anxiety, major depressive disorder, and cognitive communication deficit. Review of the most recent Minimum Data Set (MDS) assessment, dated 2/12/26, indicated he/she scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. Review of Resident #14's psychiatric Nurse Partitioner (NP) progress note, dated 3/21/26, indicated GDR Rationale(s): Recommend GDR decrease the Aripiprazole (antipsychotic medication) to 2.5 mg (milligrams) every other day for 1 week, then D/C (discontinue). Continue to monitor mood & behavior. Further review of the psych NP note indicated: Review/Discussion: Discussed with nursing; Reviewed Chart; This includes time spent on work such as documentation, chart review, discussion with patient, and other members of the care team. Review of Resident #14's physician order, dated 1/21/26, indicated Abilify (Aripiprazole) give 2.5 mg by mouth in the morning for depressive behavior. Review of Resident #14's March and April 2026 Medication Administration Record (MAR), indicated he/she received the Aripiprazole 2.5 mg daily as ordered. Review of Resident #14's behavior care plan, dated 3/31/25, indicated the following:-Attempt psychotropic drug reduction per physician orders.-Psych referral and treat as needed. Review of Resident #14's medical record failed to indicate that nursing updated the provider for the psych NP recommendations. During an interview and medical record review with the surveyor on 4/2/26 at 9:09 A.M. Unit Manager #1 said she gets the printed psych NP note and as soon as possible she would call the Resident's physician to get the recommendations approved to then put the new orders in. Unit Manager #1 said she has never had a physician decline a GDR. The Unit Manager said she does not remember these new recommendations from 3/21/26 and it was missed. During an interview on 4/2/26 at 9:11 A.M., Nurse #1 said Resident #14 has been receiving the Aripiprazole 2.5 mg every day and as far as she knows the order has no stop date. On 4/2/26 at 9:15 A.M., the Assistant Director of Nurses reviewed Resident #14's psych NP note from 3/21/26 with the surveyor and reviewed his/her physician orders and said the Resident is still on the Aripiprazole daily. During an interview on 4/2/26 at 9:18 A.M., Physician #1 said he was Resident #14's physician and nursing staff normally call him with new psych recommendations. The Physician said he was unaware of the new GDR recommendations made on 3/21/26 and does approve of the GDR of the Aripiprazole. During an interview on 4/2/26 at 9:33 A.M., Resident #14 said he/she had psych services, and the NP goes over the plan with him/her during their talks. During an interview on 4/2/26 at 9:44 A.M., the Director of Nurses said Resident #14's psych recommendations on 3/21/26 were missed by nursing staff.

Based on observations, interviews and record review, the facility failed to implement a plan of care for one Resident (#143) out of a sample of 35 residents. Specifically, the facility failed to implement a sensory diet plan of care (a personalized, occupational therapist-designed activity plan providing specific sensory input (visual, auditory, olfactory, tactile, proprioceptive and gustatory). It helps regulate the nervous system, improving focus, behavior, and emotional control).Findings include:Review of the facility policy titled 'Care Plans, Comprehensive Person-Centered' revised in March 2022 indicated the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.Review of the facility policy titled 'Dementia Care Unit Activities Program' with a revision date of 7/3/2018 indicated the following:-The Activities program on the Dementia Care Unit is designed to meet the current and changing needs of individuals with Dementia. The Activities program is designed to maintain each resident's dignity and personal identity, enhance socialization and success and to accommodate the various cognitive and functional abilities of each resident either individually or in group settings. Review of the facility policy titled 'Behavioral Assessment, Intervention, and Monitoring' with a revision date of February 2025 indicated the following:-Behavior is the response of an individual to a wide variety of factors. The factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environment causes.-Behavioral interventions refer to individualized, nonpharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical, or psychosocial well-being. Resident #143 was admitted to the facility in November 2022 with diagnoses including Dementia and anxiety disorder. Review of the most recent MDS (Minimum Data Set) assessment, dated 2/18/26, indicated a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating severe cognitive impairment Review of Resident #143's Occupational Therapy (OT) treatment encounter progress note, dated 1/23/26, indicated the following:-Date of service:1/23/26. Staff education provided on Resident's individualized sensory diet handout which details tactile, proprioceptive, gustatory, olfactory, visual and auditory sensations which have been beneficial for reducing Resident's anxiety/agitation. Copy provided for Resident's care plan; copy placed in room and a third copy provided to Activities staff on unit for continued carry over.Review of Resident #143's eye care progress note, dated 11/26/25, indicated the following:-Glaucoma suspect, open angle with borderline findings, low risk; Both eyes; borderline IOP (Intraocular Pressure) OU (Oculus Uterque, meaning both eyes) on tensing. Glasses Required? No. Eyelid Care Required? No. New Orders? No. On 3/31/26 at 8:18 A.M., the surveyor observed Resident #143's sensory diet pinned on the bulletin board next to his/her bed. The sensory diet indicated the following: Visual- Avoid mirrors which can be distressing or confusing. The surveyor observed a vanity mirror above the dresser in Resident #143's room. The vanity mirror was permanently attached to the wall and the Resident had visual access to it. On 4/1/26 at 8:52 A.M., the surveyor observed the sensory diet pinned to the Resident's bulletin board. The vanity mirror above the dresser was permanently attached to the wall in the Resident's room. During an interview and observation on 4/1/26 at 11:19 A.M., the Activities Director said she worked in collaboration with Occupational Therapist (OT). The Activities Director said OT put up the sensory diet in the Resident's room. The Activities Director reviewed the visual sensory diet and said the vanity mirror above the dresser should not be in the Resident's room. During an interview and record review on 4/1/26 at 11:29 A.M., the Director of Rehabilitation/OT reviewed a copy of the sensory diet and said the visual sensory diet should be followed by staff providing care. The DOR said the sensory diet was placed in the Resident's room on 1/23/26 after the Resident was discharged from OT. During an interview and record review on 4/1/26 at 11:45 A.M., the Unit Manager #2 reviewed the sensory diet and said she was not aware the sensory diet was in the Resident's room. The Unit Manager said if OT put up the sensory diet in the Resident's room, she expects staff to implement it at all times. The Unit Manager said she was not made aware of the visual sensory diet in the Resident's room. The Unit Manager said based on the visual sensory diet, the Resident's room should be free of mirrors. During an interview and observation on 4/1/26 at 11:49 A.M., Certified Nurse's Assistant (CNA) #1 and the Surveyor went into the Resident's room. The sensory diet was on the Resident's bedside dresser. The CNA reviewed the visual sensory diet and said she was never made aware of the sensory diet in the Resident's room. The CNA said based on where the vanity mirror was placed, the Resident could see it at all times while in the room, while sitting up in bed and while leaving the room. During an interview on 4/1/26 at 11:57 A.M., the Director of Nurses (DON) said Resident #143's sensory diet should be implemented. The DON said the vanity mirror above the dresser should not be in the Resident's room.

Based on observation, interview and record review, the facility failed to reassess and revise a plan of care for one Resident (#143) out of a sample of 35 Residents. Specifically, the facility failed to revise a sensory diet plan of care (a personalized, occupational therapist-designed activity plan providing specific sensory input (visual, auditory, olfactory, tactile, proprioceptive and gustatory). It helps regulate the nervous system, improving focus, behavior, and emotional control).Findings include:Review of the facility policy titled 'Care Plans, Comprehensive Person-Centered' revised in March 2022 indicated the following:-A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.-Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition changes.Review of the facility policy titled 'Dementia Care Unit Activities Program' with a revision date of 7/3/2018 indicated the following:-The Activities program on the Dementia Care Unit is designed to meet the current and changing needs of individuals with Dementia. The Activities program is designed to maintain each resident's dignity and personal identity, enhance socialization and success and to accommodate the various cognitive and functional abilities of each resident either individually or in group settings.-On admission, with a change in status and annually, residents will have an activities assessment. Information gathered will be used to develop the activities component of the resident's comprehensive care plan.A review of the facility policy titled 'Behavioral Assessment, Intervention, and Monitoring' with a revision date of February 2025 indicated the following:-Behavior is the response of an individual to a wide variety of factors. The factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environment causes.-Behavioral interventions refer to individualized, nonpharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical, or psychosocial well-being.Resident #143 was admitted to the facility in November 2022 with diagnoses including Dementia and anxiety disorder.Review of the most recent MDS (Minimum Data Set) assessment, dated 2/18/26, indicated a Brief Interview for Mental Status (BIMS) score of 00 out of 15 indicating severe cognitive impairment.Review of Resident #143's Occupational Therapy (OT) treatment encounter progress note dated 1/23/26 indicated the following:-Date of service:1/23/26. Staff education provided on Resident's individualized sensory diet handout which details tactile, proprioceptive, gustatory, olfactory, visual and auditory sensations which have been beneficial for reducing Resident's anxiety/agitation. Copy provided for Resident's care plan; copy placed in room and a third copy provided to Activities staff on unit for continued carry over.On 3/31/26 at 8:18 A.M., the surveyor observed Resident #143's sensory diet pinned on the bulletin board next to his/her bed. The sensory diet indicated the following: Visual- Avoid mirrors which can be distressing or confusing. The surveyor observed a vanity mirror above the dresser in Resident #143's room. The vanity mirror was permanently attached to the wall where the Resident had visual access to.On 4/1/26 at 8:52 A.M., the surveyor observed the sensory diet pinned to the Resident's bulletin board. The vanity mirror above the dresser was permanently attached to the wall in the Resident's room.During an interview and observation on 4/1/26 at 11:19 A.M., the Activities Director said she works in collaboration with OT. The Activities Director said OT put up the sensory diet in the Resident's room. The Activity's Director said the Resident's Dementia has worsened, therefore having a mirror in his/her room is not a concern. The Activities Director said the sensory diet in his/her room should be revised to reflect that change.During an interview and record review on 4/1/26 at 11:29 A.M., the Director of Rehabilitation/OT reviewed a copy of the sensory diet and said the sensory diet should be followed by staff providing care. The DOR said the visual sensory diet needs to be reassessed, revised and personalized with new information.During an interview and record review on 4/1/26 at 11:45 A.M., the Unit Manager #2 reviewed the sensory diet and said she was not aware the sensory diet was in the Resident's room. Unit Manager #2 said she expects OT to reassess and revise the sensory diet if the Resident has gone through a change in condition. Unit Manager #2 said OT should provide education to staff on the unit after the revisions are made to the visual sensory diet.During an interview on 4/1/26 at 11:57 A.M., the Director of Nurses said Resident #143's visual sensory diet should be reassessed and revised as needed.During an interview and record review on 4/2/26 at 8:45 A.M., Social Worker #1 said care plan meetings are held quarterly and change in condition conferences are held as needed. The Social Worker said family and responsible parties are invited. The Social Worker said the interdisciplinary team is invited as well. The Social worker said the Activities Director attends all quarterly care plan meetings and change in condition meetings. The Social Worker said the plan of care is discussed and if any revisions are required, they are made during the meeting. The Social Worker reviewed the medical record and said the last change in condition meeting held for Resident #143 was on 2/24/26. The meeting was held to address the Resident's change in condition; cognition was one of the topics discussed. The Social Worker said according to the meeting sign up list; the Activities Director attended the meeting.Further review of the 2/24/26 change in condition meeting conference failed to indicate that that the Resident's visual sensory diet was discussed and revised.

Based on observations, interviews, records, and policies reviewed, the facility failed to ensure that one Resident (#95) out of a total sample of 34 residents, maintained acceptable parameters of nutritional status. Specifically, the facility failed to ensure Resident #95's weight was monitored when a weight change occurred, per facility policy, and resulted in significant weight loss and failed to notify the physician after significant weight loss was identified after Resident #95's gastrostomy tube (a tube inserted into the stomach to provide nutrition) was accidentally removed and not replaced. Findings include: Review of facility policy titled 'Weight Assessment and Intervention' dated March 2023, indicated the following but was not limited to: -Resident weights are monitored for undesirable or unintended weight loss or gain. -The Dietician will respond timely to a verified significant weight change. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant. b. 6 months - 10% weight loss is significant. -The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia weight loss or increasing the risk of weight loss for example a. Fluid and nutrient loss b. Inadequate availability of food or fluids c. Increased need for calories and or protein -care planning for weight loss our impaired nutrition is a multidisciplinary effort and includes the physician nursing staff, the dietitian the consultant pharmacist and the resident legal surrogate. -individualized care plans are addressed to the extent possible they identified causes of weight loss goals and benchmark for improvement and time frames and parameters for monitoring and reassessment. -interventions for undesirable weight loss shall be based on careful consideration of the following a. Nutrition and hydration needs of the residents. b. The use of supplementation and all feeding tubes Resident #95 was admitted to the facility in October 2023 with diagnoses including Parkinson's disease, dementia, dysphagia and dependent on tube feeding, gastrostomy status, unspecified severe protein calorie malnutrition. Review of Resident #95's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) was conducted which indicated the Resident had a memory problem and was cognitively impaired. The MDS further indicated that the Resident was dependent on tube feeding. On 4/30/24 at 9:08 A.M., the surveyor observed Resident #95 lying in bed, he/she was observed to be very thin in appearance. The Resident was not able to be interviewed. Review of nursing progress note dated 3/8/24 indicated the following but not limited to: Patient removed gastrostomy- tube (g-tube ) intact, attempts to replace g-tube with foley catheter failed secondary to gastrostomy site no longer patent (accessible) medical director made aware. Order obtained to schedule patient for interventional radiology (IR) for g-tube replacement, return call pending at this time, patient on modified diet and has adequate by mouth intake to cover through weekend, encourage fluids, guardian aware, dietician and speech language pathologist following. Review of dietician progress note dated 3/8/24 indicated the following but not limited to: -Resident weight stable times one week. G-tube dislodged the morning, medical director aware, plan for g-tube replacement 3/11/24. Will optimize by mouth intake with Med pass 2.0 (a nutritional supplement) four ounces three times a day between meals. 12 ounces daily will provide 720 kilo calories and 30 grams protein. Phone the guardian without answering. Registered dietician to closely monitor. Review of the medical record indicated Resident #95 weighed 125 lbs. (pounds) on 3/7/24 at the time his/her G-tube had become dislodged. Review of Resident #95's medical record indicated the Resident weighed 119.4 lbs. (a weight loss of 4.48%) on 3/11/24, in only three days after the g-tube became dislodged. Review of Resident #95's physician notes failed to indicate that the physician was notified of the weight change from 3/7/24 to 3/11/24. Review of Resident #95's nutritional orders failed to indicate a new intervention was added to address the immediate weight loss on 3/11/24. Review of Resident #95's medical record indicated the Resident had an appointment for the G-tube to be replaced on 3/15/24. Review of nursing progress note dated 3/15/24 indicated the following but not limited to: -Patient returned from interventional radiology no g-tube placed, tract scarred and unable to be accessed, medical director (MD) aware and will follow up with MD at IR regarding appropriate plan. Review of Resident #95's weekly weights after the G-tube had failed to be replaced indicated the following: -3/20/24 109 lbs. (a significant weight loss of 12.80% since the G-tube had been dislodged.) -3/22/24 110.6 lbs. (a confirmation of the significant weight loss) -3/11/24 119.4 lbs -3/7/24 125 lbs Resident #95's medical record failed to indicate the physician was notified immediately after the continued weight loss which had become significant as of 3/20/24. In addition, the medical record failed to indicate any new nutritional interventions were put into place after the significant weight loss. Review of a dietician progress note dated 3/22/24 indicated the following: re weigh requested due to significant variation compared to previous weights slash weight trends noted GTube unable to be replaced by interventional radiology weight 109 lbs. Review of dietician progress note dated 3/23/24 indicated the following rere-weigh (sic) indicates accurate significant weight loss encouragement of by mouth fluids and food provided while patient alert and able to safely take by mouth. Appreciate nursing diligence. By mouth intake remains inadequate with subsequent weight loss pending referral for G tube replacement plan to continue to optimize current nutrition intervention ONS (oral nutritional supplements) 4 times a day fortified foods at meals and snacks slash fluids between meals wait 110.6 pounds. Review of the RD progress note dated 3/23/24 indicated the following: Reweight indicates accurate, significant weight loss, current BMI (Body Mass Index) of 15 kg/m2 indicates underweight status. Medical director and nursing aware. Nursing attempt for IV access for hydration, unable to place IV for fluids. Review of nursing note dated 3/25/24 indicated the following: MD into asses, poor by mouth intake, patient refusing to allow IV access, subcutaneous access established to left upper extremity, normal saline running at 60 milliliters per hour. On 3/26/24 the following nursing note indicated: Patient with increased lethargy, unable to swallow and by mouth, no g-tube access. Resident was transferred to the hospital. Review of history and physical report dated 3/26/24 from the hospital indicated the following: -Resident's g-tube was accidentally dislodged on 3/8/24, patient was sent to IR on 3/15/24 for replacement however tract was not salvageable. Patient was sent back to facility without enteral access or acceptable nutrition plan and no planned procedure date for G tube replacement patient only able to tolerate small amounts of by mouth intake since 3/8/24 resulting in 15 lbs. (pounds) weight loss as patient has been without necessary tube feeding to maintain weight for 20 days. Patient was found to have lost about 15 lbs. and appeared dry hence the referral to the emergency department. Review of the Adult Malnutrition Assessment form completed when the Resident was inpatient in the hospital, dated 3/29/24 indicated the following: -this patient has been identified as meeting criteria for malnutrition based on etiology-based definitions BMI calculated 16.2. Adult malnutrition code as identified by dietician severe. During an interview on 5/2/24 at 10:24 A.M., Certified Nursing Assistant (CNA) #1 said the Resident loves to eat and would eat most meals fully when awake. CNA #1 said Resident #1 was provided with cereal at breakfast and only potatoes at lunch throughout the time the G-tube was dislodged. She further said she offers him/her snacks if the Resident wants. CNA #1 said she does not remember offering the Resident snacks when the tube feeding was dislodged. On 5/2/24 at 12:36 P.M., the surveyor asked the Food Service Director to print out Resident #95's meal ticket. Review of the diet slip provided by the food service director for Resident #95 indicated the following: -Breakfast pureed small portion: Mildly thick cranberry juice and puree hot cereal only. -Lunch Pureed small portion: Mildly thick cranberry juice super mashed only for lunch no dessert. -Dinner pureed small portion: Mildly thick cranberry juice puree protein only for supper no dessert. The Food Service Director said the meal ticket had been the same with the same portions with no changes since the previous month. During an interview on 5/2/24 at 10:26 A.M., Unit Manager #1 said all the residents on the short-term unit are on weekly weights unless otherwise ordered. She said the Unit Manager and the Registered Dietician are responsible for looking at the weights and recognizing weight changes. If weight loss notification is done to RD, MD, and resident representatives. Furthermore, interventions are made immediately. The UM said that she believed the Resident weights had been stable as the Resident was eating by mouth when the feeding tube had dislodged. The UM confirmed that a weight loss had occurred on 3/11/24 and no new intervention had been added. The UM said the Resident feeding tube was not replaced until 3/26/24 and at that time the Resident had lost significant weight. The UM said the Medical Director had not seen the Resident as the Resident did not have a skilled need. During an interview on 5/2/24 at 9:14 A.M., the Registered Dietician (RD) said the Resident was dependent on tube feeding for his/her daily caloric intake. She said the Resident ate pleasure foods by mouth only when arousable. She said the physician was aware that the Resident was dependent on tube feeding when the tube feed had dislodged. The RD said the intake of pleasure feeding was between 25-75% of meals and snacks offered. The RD said she did not check on the Resident's daily food consumption when the tube feeding was dislodged. The RD said she had added med pass 2.0 on 3/8/24 which was the only new intervention added throughout the period of weight loss. The RD said the physician was aware the tube feed needed to be replaced but was not aware of the initial weight loss on 3//11/24. The RD said she wrote an email to the MD on 3/22/24 inquiring about the status of the g-tube replacement as the Resident had lost 10 lbs. since the tube dislodged. The surveyor reviewed the correspondence to the MD from the RD dated 3/22/24. During an interview on 5/2/24 at 9:44 A.m., the Medical Director said he was relying on nursing staff to communicate with him regarding Resident #95's care. The MD said the nursing staff had made him aware that the Resident's intake had been adequate since the g-tube had dislodged on 3/8/24, but said he was unaware the Resident was still only eating a pleasure food portion, not a full meal. He further said there was a delay in his part, and he should have sent the Resident to the hospital sooner had he been aware that the Resident was having a rapid decline in weight loss. The MD said when he saw the Resident on 3/25/24 the Resident was dehydrated, his/her ability to swallow had declined and IV fluids had been started two days before the Resident was transferred to the hospital. The MD said the Resident should have been monitored closely due to being at high risk for dehydration and the fact that the Resident who depended on tube feeding for his daily intake needs was not getting the same amount of intake. The MD said that he never received an email communication from the RD on 3/22/24 regarding concerns with Resident #95. During an interview on 5/2/24 at 12:39 P.M., the Director of Nursing said the risk team did not follow the Resident as he/she resided in the short-term unit. She further said the RD should have monitored the Resident closely, as the RD would be the one to make recommendations to the MD. Refer to F693

Based on observations, interviews, policy and record reviews, the facility failed to ensure that one Resident (#95) of one applicable resident, in a total sample of three residents, who received enteral nutrition (method of delivering nutrition through the stomach or the small intestine) via a gastrostomy tube (G-tube: tube inserted through the abdomen into the stomach to provide nutrition) received care and services to prevent complications. Specifically, the facility failed to ensure that fluids were administered and monitored to maintain acceptable parameters of hydration, after the tube was dislodged on 3/8/24 resulting in clinical signs of dehydration and need for the administration of intravenous fluids (IV fluids: specifically formulated liquids that are injected into a vein to prevent or treat dehydration) for the Resident. Resulting in a rehospitalization on [DATE], 18 days after the tube was dislodged. Findings Include: Review of the facility policy titled 'Enteral Nutrition Feedings' dated revised July 2023, indicated the following but not limited to: -It is the policy of this center to provide enteral nutrition therapy to residents unable to obtain nourishment orally when such therapy is ordered by the physician and not clinically contraindicated. -Flush tube with an additional 30-60 (ml) milliliters of water or administer prescribed flushing volume prior to initiating tube feeding. Always flush with water that is approximately room temperature to avoid abdominal cramping. Review of the facility policy titled 'Resident Hydration and Prevention of Dehydration' revised October 2017, indicated the following but not limited to: -This facility will strive to provide adequate hydration and to prevent and treat dehydration. -The dietician will assess all residents for hydration as part of the comprehensive assessment, at least quarterly, and more often as necessary per resident need. -Nurses will assess for signs and symptoms of dehydration during daily care. -If potential inadequate intake/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into a care plan. -Activities of Daily Living (ADL) status, diagnosis, individual preference, habits, and cognitive and medical status will be considered in all interventions. -The physician will be notified. -The dietician, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake. -Laboratory tests may be ordered to assess hydration; the physician may initiate IV hydration. hospitalization will be recommended as necessary. Review of the Merck Manual article, Hypernatremia ([NAME], [DATE]) at https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/electrolyte-disorders/hypernatremia indicated the following: -In hypernatremia, the level of sodium in blood is too high -Hypernatremia involves dehydration, which can have many causes, including not drinking enough fluids . -Blood tests are done to measure the sodium level -Usually, fluids are given intravenously to slowly reduce the sodium level in the blood. Resident #95 was admitted to the facility in October 2023 with diagnoses including Parkinson's disease, dementia, dysphagia and dependent on tube feeding. Review of Resident #95's Minimum Data Set (MDS) dated [DATE] indicated a Staff Assessment for Mental Status was conducted which indicated the Resident had short term and long-term memory problem and was severely impaired and never/rarely made any decisions. The MDS further indicated that the Resident was dependent on tube feeding. Review of Resident #95's diet care plan date revised 10/4/21 indicated the following interventions: -Enteral nutrition per physician's orders -Solids puree solids -Liquid consistency: Mildly Thick Nutrition noted dated 2/29/24 indicated the Resident was receiving the following: -Jevity 1.5 at 60 milliliter/ hour times 24 hours with goal of infusion of 20 hours to provide 1200 ml formula, 1800 kcals, 76-gram protein and 916 ml water. Active physician orders indicated if patient removes g-tube, replace immediately with foley catheter to maintain patency, notify MD. Review of the medical record failed to indicate the Resident was being monitored for intake or output when the tube feed had dislodged. Review of nursing progress note dated 3/8/24 indicated the following but not limited to: Patient removed gastrostomy- tube (g-tube) intact, attempts to replace g-tube with foley catheter failed secondary to gastrostomy site no longer patent (accessible) medical director made aware. Order obtained to schedule patient for interventional radiology (IR) for g-tube replacement, return call pending at this time, patient on modified diet and has adequate by mouth intake to cover through weekend, encourage fluids, guardian aware, dietician and speech language pathologist following. Review of dietician progress note dated 3/8/24 indicated the following but not limited to: -Resident weight stable times one week. G-tube dislodged the morning, medical director aware, plan for g-tube replacement 3/11/24. Will optimize by mouth intake with Med pass 2.0 (nutritional supplement) four ounces three times a day between meals. 12 ounces daily will provide 720 kilo calories and 30 grams protein. Phone the guardian without answering. Registered dietician to closely monitor. Review of nursing progress note dated 3/15/24 seven days after feeding tube had dislodged indicated the following but not limited to: -Patient returned from interventional radiology no g-tube placed, tract scarred and unable to be accessed, medical director (MD) aware and will follow up with MD at IR regarding appropriate plan. The medical record failed to indicate a plan was in place to maintain Resident #95 ' s intake and hydration as he/she was totally dependent on tube feeding for daily caloric intake. Review of the RD progress note dated 3/23/24 18 days after the tube had dislodged, indicated the following: Reweight indicates accurate, significant weight loss on 3/8/24 125.0 lbs and on 3/23/24 110.6 lbs current BMI (Body Mass Index) of 15 kg/m2 indicates underweight - 10% change. Medical director and nursing aware. Nursing attempt for IV access for hydration, unable to place IV for fluids. Review of nursing note dated 3/25/24 indicated the following: MD into asses, poor by mouth intake, patient refusing to allow IV access, subcutaneous access established to left upper extremity, normal saline running at 60 milliliters per hour. On 3/26/24, 18 days after the tube was dislodged the following nursing note indicated: Patient with increased lethargy, unable to swallow and by mouth, no g-tube access. Resident was transferred to the hospital. Review of Resident #95 ' s weights indicated the following: -3/22/24 110.6 lbs -3/20/24 109 lbs -3/11/24 119.4 lbs -3/7/24 125 lbs Review of the clinical record included the following lab work obtained on the following dates: -2/26/24 Sodium 141 (normal range) measures sodium in blood. -2/26/24 Creatinine 0.67 (normal range 0.55-1.30) measures efficiency of kidneys -2/26/24 BUN 21 (Blood urea nitrogen) (normal range 6-24) measures how well your kidneys are functioning. -3/25/24 Sodium 160 (high) (normal range 135-146) measures sodium in blood. -3/25/24 BUN 66 (high) (normal range 6-24) measures how well your kidneys are functioning. -3/25/24 Creatinine 1.60 (high) (normal range 0.55-1.30) measures efficiency of kidneys Review of the history and physical report, dated 3/26/24 from the hospital indicated Resident #95 was diagnosed with dehydration upon admission to the hospital and indicated the following: -Resident's g-tube was accidentally dislodged on 3/8/24, patient was sent to IR on 3/15/24 for replacement however tract was not salvageable. Patient was sent back to facility without enteral access or acceptable nutrition plan and no planned procedure date for G tube replacement patient only able to tolerate small amounts of by mouth intake since 3/8/24 resulting in 15 lbs (pounds) weight loss as patient has been without necessary tube feeding to maintain weight for 20 days. Patient was found to have lost about 15 lbs and appeared dry hence the referral to the emergency department sodium level 165. During an interview on 5/2/24 at 9:44 A.M., the Medical Director said he was relying on nursing staff to communicate with him regarding Resident #95's care. The MD said the nursing staff had made him aware that the Resident's intake had been adequate since the g-tube had dislodged on 3/8/24. He further said there was a delay in his part, and he should have sent the Resident to the hospital sooner. The MD said when he saw the Resident on 3/25/24 the Resident was dehydrated, his/her ability to swallow had declined and IV fluids started two days before the Resident was transferred to the hospital. The MD said the Resident should have been monitored closely due to being at high risk for dehydration. During an interview on 5/2/24 at 11:26 A.M., the Registered Dietician (RD) said she encouraged nursing staff to provide more fluids to the Resident to replace the hydration that the Resident would have received from the feeding tube. She further said since the Resident had required tube feeding 100 percent for his/her nutritional support and hydration, he/she should have monitored closely as an at risk for dehydration. The RD said she advocated for the tube feed to be replaced sooner. During an interview on 5/2/24 at 12:39 P.M., the Director of Nursing said the risk team did not follow the Resident as he/she resided in the short-term unit. She further said the RD should have monitored the Resident closely. The Director of Nursing said that her expectation is that the RD would be the one to make recommendations to the MD.

Based on observations, interviews, and policy review, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to properly secure medication carts on two of four units. Findings include: Review of the facility's policy titled Medication Labeling and Storage, revised February 2023, indicated, but was not limited to: -The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. -The nursing staff is responsible for maintaining medication storage. -Compartments (including carts) containing medications and biologicals are locked when not in use, and the trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 1.) The surveyor made the following observations on the [NAME] Unit: -On 5/1/24 at 9:00 A.M., the surveyor observed the medication cart on A side of [NAME] unit unlocked and unattended. Nurse #3 was not in the hallway and not within sight of the medication cart. -On 5/1/24 at 9:19 A.M., Nurse #3 left the A side medication cart unlocked and went down the hall out of view of the medication cart before returning and going into a resident room, which also was not within sight of the medication cart. During an interview on 5/1/24 at 9:01 A.M., Nurse #3 said he was assigned to the A side medication cart on the [NAME] unit and that he should not have left the medication cart unlocked and unattended. During an interview on 5/2/24 at 8:07 A.M., the Director of Nursing said medication carts should be locked if the nurse is not within sight of the medication cart. 2.) The surveyor made the following observation on the [NAME] Unit: -On 5/2/24 at 6:37 A.M., the medications carts were observed to be unlocked and unattended. There was a resident near the unlocked cart. During an interview on 5/12/24 at 6:40 A.M., Nurse #2 said medication carts should be locked if unattended. During an interview on 5/2/24 at 8:07 A.M., the Director of Nursing said medication carts should be locked if the nurse is not within sight of the medication cart. 46339

Based on record review and interview, the facility failed to provide care and service for an indwelling Foley catheter (urinary catheter which remains in the bladder to provide continuous urine drainage. A balloon inflated at the catheter's distal end prevents it from slipping out of the bladder after insertion) for one Resident (#83), out of a total sample of 34 residents. Specifically, for Resident #83, the facility failed to ensure the physician's order for changing/inserting the Foley catheter included catheter size/type and balloon size. Findings include: Resident #83 was admitted to the facility in March 2024 with diagnoses including retention of urine, obstructive and reflux uropathy. Review of Resident #83's Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 11 out of 15 on the Brief Interview for Mental Status (BIMS) score indicating that he/she had moderate cognitive impairment. The MDS further indicated the Resident had an indwelling foley catheter. Record review of a document titled 'Resident Evaluation-MA-V4' dated 3/31/24, indicated the Resident had an indwelling foley catheter, the record revealed no initial/admission documentation by the nursing staff addressing the Foley catheter size and balloon size that the Resident had in place when admitted . Review of the current physician orders indicated the following but not limited to: *Foley catheter -Every night shift every Saturday change the catheter secure tube holder and, -As needed change urinary catheter with French size:____ and Balloon size:____ The current physician's order did not indicate the size of the Foley catheter and balloon size to be reinserted if the Foley catheter needed to be changed. Review of care plan titled use of indwelling urinary catheter date initiated 3/31/24 failed to indicate the foley catheter size and balloon size. During an interview on 5/1/24 at 11:12 A.M., Nurse #1 said the physician orders for urinary catheter should have the size of the catheter and balloon indicated. During an interview on 5/2/24 at 8:20 A.M., the Director of Nursing said it is not in their policy to have orders indicating the size and balloon for foley catheter and if a reinsertion was required, they would start with a small size.

Based on record review and interviews, the facility failed to notify the physician of a significant weight loss for one Resident (#95) out of a total sample of 34 residents. Specifically, the facility failed to notify physicians of the significant weight loss on Resident #95 who was totally dependent on tube feeding for his/her daily nutritional needs. Findings include: Resident #95 was admitted to the facility in October 2023 with diagnoses including Parkinson's disease, dementia, dysphagia and dependent on tube feeding. Review of Resident #95's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) was conducted which indicated the Resident had memory problem and was cognitively impaired. The MDS further indicated that the Resident was dependent on tube feeding. Review of Resident #95 diet care plan date revised 10/4/21 indicated the following interventions: -Enteral nutrition per physician's orders -Solids puree solids -Liquid consistency: Mildly Thick Review of Resident #95 ' s weights indicated the following: -3/22/24 110.6 lbs -3/20/24 109 lbs -3/11/24 119.4 lbs -3/7/24 125 lbs Review of Resident #95 weights care plan last revised 4/4/24 indicated the following interventions: -Notify physician and responsible party of significant weight changes. Review of Resident #95's physician notes failed to indicate that the physician was notified of the significant weight changes from 3/7/24 at 125.0 lbs. (pounds) to 119.4 lbs. on 3/11/24 and continued to trend downwards. During an interview on 5/2/24 at 9:14 A.M., the Dietician said the Resident was relying on tube feeding 100% for daily nutritional value. The Dietician further said that the Physician should have been made aware of the Resident's significant weight loss sooner. During an interview on 5/2/24 at 9:44 A.M., The Medical Director said the nursing staff did not alert him to the significant weight loss on 3/11/24 where the Resident had lost 5.6 lbs (4.48%) three days after the tube had dislodged. The physician said he would have sent the Resident out to the hospital sooner for further intervention had he known that the Resident's intake was inadequate. The Medical Director said there was a delay in treating the Resident due to the lack of communication. During an interview on 5/2/24 at 12:39 P.M., the Director of Nursing said the dietician was responsible for monitoring the Resident's weight and should have notified the physician of the changes in the Resident's weight.

Based on observations, policy review, record review, and interviews for two Residents (#30 and #138) out of five Residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5% when two of four nurses observed made three errors out of 29 opportunities resulting in a medication error rate of 10.34%. Specifically, 1.) For Resident #30, the nurse administered the incorrect form and incorrect medication. 2.) For Resident #138, the nurse administered to incorrect medication. Findings include: Review of facility policy titled Administering Medications, revised April 2019, indicated, but was not limited to: -Medications are administered in a safe and timely manner, and as prescribed. -Medications are administered in accordance with prescriber orders. 1.) Resident #30 was admitted to the facility in September 2023 with diagnoses including asthma and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 3/21/24, indicated that Resident #12 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 12 out of 15. On 5/1/24 at 9:04 A.M. the surveyor observed Nurse #3 prepare and administer the following medications to Resident #30: -Enteric coated aspirin tablet, 81 milligrams (mg). -Multivitamin with minerals tablet. Review of Resident #30's active physician orders indicated the following: -Aspirin tablet chewable 81 mg, give 1 tablet by mouth one time a day, initiated 9/27/23. -Multivitamin oral tablet, give 1 tablet by mouth one time a day, initiated 9/22/23. During an interview on 5/1/24 at 12:51 P.M., Nurse #3 said he should have checked the order, but did not, and administered enteric coated aspirin instead of chewable aspirin, which was an error. Nurse #3 said administering the multivitamin with minerals was also an error, and he should have administered a different type of multivitamin without minerals. Nurse #3 showed the surveyor a new bottle of multivitamins, without minerals, and said this was the medication he should have given. During an interview on 5/1/24 at 1:12 P.M., the Director of Nursing (DON) said medications should be given as ordered by the physician. The DON said aspirin should not have been given in enteric coated form because it was ordered in chewable form. The DON said a multivitamin with minerals requires a specific order for minerals, and that Resident #30 should not have received a multivitamin with minerals. The DON said this was an error. 2.) Resident #138 was admitted to the facility in April 2024 with diagnoses including bladder cancer and urinary tract infection. Review of the most recent Minimum Data Set (MDS) assessment, dated 4/21/24, indicated that Resident #138 was cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 5/1/24 at 9:38 A.M. the surveyor observed Nurse #4 prepare and administer the following medications to Resident #138: -Multivitamin with iron tablet. Review of Resident #138's active physician orders indicated the following: --Multivitamin/Minerals tablet, give 1 tablet by mouth one time a day, initiated 4/18/24. During an interview on 5/1/24 at 1:12 P.M., the Director of Nursing (DON) said medications should be given as ordered by the physician. The DON said Resident #30 should not have received a multivitamin with iron because iron requires a specific order, and the order was for multivitamin with minerals, not iron. The DON said this was an error.

Based on record review and interviews, the facility failed to maintain accurate medical records for one Resident #95 out of a total sample of 34 residents. Specifically, the facility failed to complete daily documentation for Activities of Daily Living (ADLs). Resident #95 was admitted to the facility in October 2023 with diagnoses including Parkinson's disease, dementia, dysphagia. Review of Resident #95's Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) was conducted which indicated the Resident had memory problem and was cognitively impaired. The MDS further indicated that the Resident was dependent on staff for total care. Review of the eating documentation section on the document titled, 'Documentation Survey Report' for February, March and April 2024, indicated documentation was incomplete for 21 shifts out of the 90 days. During an interview on 5/2/24 at 10:24 A.M., Certified Nursing Assistant (CNA) #1 said documentation for all ADLs should be complete and no holes (incomplete sections) should be left. During an interview on 5/2/24 at 1:30 P.M., the Director of Nursing said all ADLs should be documented daily.

Based on observations and interviews, the facility failed to maintain a homelike environment on 2 of 4 resident units. Findings include: 1. During environmental rounds on 3/1/23 at 9:40 A.M., the following was observed on the first-floor [NAME] unit: *In room [ROOM NUMBER], wallpaper was peeling behind the B bed. *In room [ROOM NUMBER], wallpaper was peeling behind the A bed. *In room [ROOM NUMBER], the baseboard at the corner of the wall between the bathroom and the A bed was peeling away from the wall. *In room [ROOM NUMBER], the A bed television (TV) table had many scratches all over it. *In room [ROOM NUMBER], the B bed side windowsill was chipped and splintered showing exposed wood, the privacy curtain had numerous stains and there was a plaster spot on top of wallpaper behind the bed. *In room [ROOM NUMBER], wall paper was peeling behind the A bed, the TV stand for the B bed was splintered and peeling upwards exposing jagged wood. *In room [ROOM NUMBER], the clothing wardrobe door had wooden trim peeling outward. *In room [ROOM NUMBER], the clothing wardrobe had numerous scratches on the side of the furniture. *In room [ROOM NUMBER], wallpaper was peeling and ripping from the wall behind the B bed. 41019 The following was observed on 2/26/23 on the [NAME] unit: - room [ROOM NUMBER] B: wallpaper was peeling behind and above to the left of the bed - room [ROOM NUMBER] B: wallpaper was off underneath the window - room [ROOM NUMBER] B: wall was scratched behind the bed and the wallpaper was peeling underneath the window During an interview on 3/01/23 at 11:10 A.M., the Maintenance Director said that there is an email system to be notified of repairs and rounds are done 1-2 times a week. The Maintenance Director said that he writes down repairs as he goes, but doesn't keep a log. He said that repairs are usually done when rooms are cleared out or when the long term care residents are out of their rooms. The Maintenance Director said that the only current project was room [ROOM NUMBER].

Based on observation, policy review, and interview, the facility failed to maintain appropriate infection control practices by 1. failing to dispose of a used bandage for 1 Resident (#135), 2. failed to ensure proper hand hygiene was performed during medication administration pass and respiratory care, 3. failed to properly wear personal protective equipment, and 4. failed to use appropriate PPE when providing respiratory care. Findings include: 1. Resident #135 was admitted in 12/2022 with diagnoses including depression and hypertension. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #135 scored a 12 out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate impairment. During an observation on 2/26/23 at 10:12 A.M., Resident #135 was sitting in his/her chair with a bedside table next to him/her. There were two used bandages on the bedside table with a pink and yellowish residue. Resident #135 said that the nurse came in to change his/her dressing and left it on the table. 43846 2. Review of the Facility's Policy titled, Handwashing/Hand Hygiene, revised August 2015, indicated to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: b. Before and after direct contact with residents; c. Before preparing medications The Policy further indicated that all personnel shall follow the handwashing/hand hygiene procedures to help to prevent the spread of infections to other personnel, residents and visitors. During medication administration pass on 3/1/23 the following were observed: * Nurse #1 at 7:29 A.M. was observed entering a resident room to administer medications and did not perform hand hygiene. * Nurse #1 at 8:03 A.M. was observed entering a resident room to administer medications and did not perform hand hygiene. * Nurse #1 at 8:06 A.M. was observed entering a resident room to administer medications, touched the bathroom door handle and did not perform hand hygiene. * Nurse #1 at 8:24 A.M. was observed entering a resident room to administer medications, touched the bathroom door handle and did not perform hand hygiene. During an interview on 3/1/23 at 8:25 A.M., Nurse #1 acknowledged she should have performed hand hygiene prior to entering any resident room. * Nurse #2 at 8:34 A.M. was observed entering a resident room to administer medications and did not perform hand hygiene. During an interview on 3/1/23 at 8:35 A.M., Nurse #2 said the expectation is to perform hand hygiene before entering a resident room. * Nurse #3 at 8:50 A.M. was observed to take a medication capsule out of the medication cup and was observed to open the capsule without gloves on, then poured the medication into the applesauce without gloves, was then observed to give the medication in the applesauce to the resident and did not perform hand hygiene prior to opening the capsule. During an interview on 3/1/23 at 8:51 A.M., Nurse #3 acknowledged he did open the capsule of medication with non-gloved hands and said he should have performed hand hygiene and donned gloves prior to opening the medication. * Nurse #3 at 8:52 A.M. was observed entering a resident room to administer medications and did not perform hand hygiene. During an interview on 3/1/23 at 8:53 A.M., Nurse #3 said the expectation is to perform hand hygiene prior to entering the resident room but he did not notice a hand sanitizing dispenser outside of the resident's room. During an interview on 3/01/23 at 9:44 A.M., the Director of Nursing said the expectation when a nurse is opening a medication would be to open the medication with gloves on and not with bare hands. During an interview on 3/01/23 at 9:44 A.M., the Director of Nursing said the expectation for staff is to perform hang hygiene before entering a resident's room and prior to leaving the residents room. 45984 3. Review of the facility policy titled Personal Protective Equipment, revised and edited on 9/16/2021 indicated the following: *Personnel who perform tasks that may involve exposure to blood/body fluids are provided appropriate personal protective equipment (PPE) at no charge. *Personal protective equipment provided to our personnel includes but is not necessarily limited to: b. Gloves (sterile, non-sterile, heavy duty and/or puncture -resistance) c. Masks The surveyor made the following observations: *On 2/26/23 at 7:49 A.M., Nurse #2 was observed at the medication cart on the resident unit with her mask below her chin, exposing her mouth and nose. The nurse proceeded into a resident room to administer medication with her mask below her chin, the nurse exited the room, went to the medication cart, and entered the same resident room again with the mask below her chin. *On 2/26/23 at 8:00 A.M., Nurse #2 was observed with her mask below her chin exposing her mouth and nose at the same medication cart on the resident unit. *On 2/26/23 at 8:17 A.M. and 9:22 A.M., Nurse #4 was observed with her mask below her nose, exposing her nose while at the nursing station of a resident unit. *On 2/26/23 at 1:28 P.M., Nurse #2 was observed with her mask down below her chin exposing her mouth and nose while in the hallway of a resident unit. During an interview on 3/1/23 at 7:45 A.M., the Director of Nursing said her expectations would be for staff to be wearing masks covering their noses and mouths at all times while on resident units. 46339 4. The surveyor made the following observations: *On 2/27/23 at 8:14 A.M., the surveyor observed Respiratory Therapist #1 go in and out of resident rooms without performing hand hygiene. On 2/27/23 at 8:17 A.M., the surveyor observed Respiratory Therapist #1 carry a suction canister half filled with liquid with no gloves on and emptied the contents in the bathroom. During an interview on 2/27/23 at 8:21 A.M., the Respiratory Therapist #1 said he should have worn gloves to empty the contents in the suction canister.

Based on observation, record review and interview, the facility failed to implement a care plan for safe smoking for 1 Resident (#39) out of a total sample of 34 residents. Findings include: Resident #39 was admitted to the facility in April 2016 with diagnoses that include Chronic Obstructive Pulmonary Disease, muscle weakness and hypertension (high blood pressure). Review of Resident #39's most recent Minimum Data Set (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 15 out of a possible 15, which indicated that the Resident is cognitively intact. Further review of the MDS indicated that Resident #39 requires supervision with locomotion on and off the unit, extensive assistance with all other activities of daily living and exhibited no behaviors. During an interview on 2/26/23 at 11:49 A.M., Resident #39 told the surveyor he/she had his/her cigarettes and lighter in his/her pocket. The Resident continued to say staff trust him/her and he/she has been here long enough. During an interview on 2/27/23 at 1:00 P.M., Resident #39 showed the surveyor his/her cigarettes that were in his/her pocket. Review of Resident #39's physician orders dated 3/31/21 indicate the following: may participate in independent smoking up to four times daily. Review of Resident #39's care plan for Safe Smoking dated 12/20/2016 indicated the following: *Interventions/Tasks: Secure smoking materials (cigarettes, matches, lighters etc.) at the nursing station. Review of Resident #39's most recent quarterly safe smoking evaluation dated 12/12/22 indicated the following: * Patient understands that smoking accessories (cigarettes, lighters, matches etc.) must be returned to and kept under the control of the center staff when not in use - this response was checked off as Yes During an interview on 2/27/23 at 1:16 P.M., Unit Manager #2 said Resident #39 is allowed to have cigarettes with him/her but not a lighter. During an interview on 3/1/23 at 7:47 A.M., the Director of Nursing said she would expect the care plan and safe smoking evaluation to be followed for Resident #39 and needs to update it.

Based on record review and interview, the facility failed to obtain a written consent for the antipsychotic medication Olanzapine (a medication used to treat Schizophrenia and Bipolar disorder) for 1 Resident (#118) out of a total sample of 34 residents. Findings include: Resident #118 was admitted in 12/2022 with diagnoses including depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #118 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate impairment. Review of the facility policy titled Antipsychotic Medication Use, dated July 2022, indicated the following: - In states with specific requirements pertaining to the use of antipsychotic medications, their consent, documentation, review, etc. state-specific requirements are adhered to. Review of the current physician orders indicated that Resident #118 is currently prescribed Olanzapine (an antipsychotic medication used to treat Schizophrenia or Bipolar disorder) 3.75 milligrams, twice a day. Review of the clinical record did not indicate that there was a signed consent for Olanzapine. During an interview on 2/27/23 at 12:25 P.M., Unit Manager #3 said that there should be a consent for Olanzapine in the chart.

Based on record review and interview, the facility failed to investigate an allegation of neglect for 1 Resident (#23) out of a total sample of 34 residents. Findings include: Review of the facility policy Abuse and Neglect- Clinical Protocol, dated March 2018, indicated the following: - Neglect as defined at 483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress - Along with staff and management, the physician will help identify situations that might constitute or could be construed as neglect. - The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Resident #23 was admitted in 11/2020 with diagnoses including anxiety and major depressive disorder. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #23 scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS), which indicates intact cognition. Review of the progress notes indicated that on 2/12/23, Resident #23 verbalized intent to harm his/herself with the call bell light cord and was sent to the hospital for evaluation. Review of the hospital discharge paperwork, dated 2/14/23, indicated that there was a behavioral health consult and the following was reported by Resident #23: - On interview, the patient reports that . do not like doing it it was bleeding but he left me there and I wound up having to stay on the toilet from 4 A.M. until noon just waiting. He/she apparently has a behavior of spending excessive time in the bathroom. During an interview on 2/27/23 at 1:34 P.M., the Director of Nursing said that if a resident makes an allegation of neglect or abuse, the Director of Nursing immediately determines if it is an allegation or a customer care concern. The Director of Nursing said that she would have expected an allegation of being left on the toilet for a long period of time to be investigated. The Director of Nursing said that there must have been a breakdown in the filing system of hospital paperwork because she was not aware that the allegation was made to the hospital or why it was never reported to her when the paperwork was reviewed.

Based on record review and interview, the facility failed to 1. update the care plan for self harm/suicide risk for 1 Resident (#23) and 2. failed to update the care plan for Activites of Daily Living (ADL) for 1 Resident (#105) out of a total sample of 34 residents. Findings include: 1. Resident #23 was admitted in 11/2020 with diagnoses including anxiety and major depressive disorder. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #23 scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS), which indicates intact cognition. Review of the care plan, dated 2/12/23, indicated the following: - Focus: Potential to Self Harm/Suicide risk: Resident #23 has a history of of SI (suicidal ideation), including statements and prior threats, recent inpatient section 12 psych stay - Interventions: Replace call light cords with hand held bells (initiated 2/14/23). During an observation on 2/27/23 at 1:53 P.M., Resident #23 was laying in bed next to his/her call light. During an observation on 3/01/23 at 7:58 A.M., Resident #23 had his/her call light in reach in bed. During an interview on 3/1/23 at 8:01 A.M., Unit Manager #3 said that Resident #23 had been cleared, on 2/15/23, to have his/her call light in reach and that the care plan should have been updated. 43846 2. Review of the Facility's Policy titled, Care Plans Comprehensive Person-Centered, dated 4/25/22, indicated that assessments of the residents are ongoing and care plans are revised as information about the residents and the residents conditions change. Resident #105 was admitted to the facility in August 2020 with diagnoses that included dysphagia, Parkinson's disease and dementia. Review of Resident #105's most recent Minimum Data Set (MDS) dated [DATE], indicated BIMS of 99, which indicates severe cognitive impairments. The MDS also indicated that Resident #105 is an extensive assist of one person for eating. During an observation on 2/26/23 at 8:28 A.M., the surveyor observed Resident #105 alone in the dining room struggling to bring food to his/her mouth and observed that none of his/her drink cartons were opened to consume. Review of Resident #105's Speech Therapy Discharge Summary dated 2/23/23, indicated consultation with therapists to facilitate patient's highest level of functional independence and correspondence with primary caregivers to facilitate development and follow-through of patient's plan of treatment. Review of Resident #105's Kardex dated 2/27/23, indicated Assist with feeding. Review of Resident #105's Activity of Daily Living Care Plan dated 9/29/20, indicated an intervention dated 6/21/22 as Assist with feeding. During an interview on 2/27/23 at 2:53 P.M., Speech Therapist #1 said Resident #105 has fluctuations with their status with eating and said the care plan should already reflect that. During an interview on 3/01/23 at 9:45 A.M., the Director of Nursing said Resident #105's care plan and kardex should have been updated to show Resident #105's correct eating status.

Based on record review and interview, the facility failed to ensure that 1 Resident (#118), had the appropriate diagnoses before administering an antipsychotic medication, out of a total sample of 34 residents. Findings include: Resident #118 was admitted in 12/2022 with diagnoses including depression. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #118 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate impairment. Review of the facility policy, titled Antipsychotic Medication Use, dated July 2022, indicated the following: - Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the medical record, consistent with the definition(s) in the Diagnostic and Statistic Manual of Mental Disorders (current or subsequent editions): - a. schizophrenia - b. Schizoaffective Disorder - c. Schizophreniform disorder - d. Delusional disorder - Mood disorders (bipolar; depression with psychotic features, and treatment refractory major depression) - Psychosis in the absence of dementia - Medical illness with psychotic symptoms - Diagnoses alone that do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: - The behavioral symptoms present as a danger to the resident or others; AND: - The symptoms are identified as being due to mania or psychosis Review of Resident #118's care plan indicates the following: Focus: At risk for adverse effects related to use of anti-depression medication, use of antipsychotic medication, anxiolytic Review of the current physician orders indicated that Resident #118 is currently prescribed Olanzapine (an antipsychotic medication used to treat Schizophrenia or Bipolar disorder) 3.75 milligrams, twice a day for anxiety. Review of the current diagnoses list for Resident #118 did not indicate that Resident #118 had any diagnoses of psychosis or delusions. Resident #118 has a diagnosis of major depressive disorder and dementia with behavioral disturbance, but no diagnoses related to psychosis. During an interview on 3/1/23 at 12:36 P.M., Unit Manager #3 said that behaviors are documented in the computer under the task section or in progress notes. Review of the clinical record did not indicate that Resident #118 has had any behaviors. During an interview on 3/1/23 at 9:59 A.M., the Director of Nursing said that she believes there are only two approved diagnoses, which are Schizoprenia and Huntington's disease for the use of an antipsychotic medication. If a resident has dementia with behavioral disturbance, then behaviors should be tracked. The Director of Nursing said that Resident #118 is not appropriate for therapy services due to his/her dementia and the physician is responsible for determining appropriate diagnoses for someone on an antipsychotic. The Director of Nursing said that Resident #118 was prescribed Olanzapine for his/her anxiety.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was admitted to the Facility for a short term respite stay, and had a history of a seizure disorder for which he/she required administration of anticonvulsant/anti-seizure medication, the Facility failed to ensure nursing notified the physician when his/her anticonvulsant/anti-seizure medication was not administered, per physician's orders. Resident #2's admission physician's orders indicated to administer Vimpat (anticonvulsant medication) 100 milligrams (mg) twice daily. However, the physician was not notified that the Vimpat had not been delivered from the pharmacy, that his/her scheduled doses were omitted (not administered) by nursing, and as a result, he/she missed 10 consecutive doses of the medication. On the day of Resident #2's planned discharge, he/she exhibited signs and symptoms of a change in condition with a decline in status, and experienced seizure activity. Findings include: The Facility Policy, titled Change in a Resident's Condition or Status, dated 02/2021, indicated staff would promptly notify the resident, his/her attending physician, and the resident's representative of changes in the resident's medical condition, and document in the resident's medical record any information relative to changes in the resident's medical condition. The Facility's Internal Investigation Report, undated, indicated Resident #2 was admitted to the Facility for a five-day period (Respite Stay), and on the day of admission Nurse Practitioner #1 did not write a prescription for his/her Vimpat. The Investigation Report indicated that during this time, four nurses that were assigned to provide his/her care, did not administer Resident #2's Vimpat, and all of them assumed there was a delay in receiving it from the pharmacy. Resident #2 was admitted to the Facility in January 2023, diagnoses included epilepsy (seizure disorder), neoplasm (tumor) of the brain, pleural effusion (fluid surrounding the lung), and obstructive uropathy. Review of Resident #2's Medication Review Report, dated 01/18/23, and signed by Nurse Practitioner (NP) #1 on 01/20/23, indicated Resident #2 physician's orders for medications included the administration of the following; -Vimpat (anticonvulsant, used for seizures) tablet, 100 mg by mouth two times a day. Review of WebMD, Uses, Side Effects, and More related to Vimpat (Lacosamide an anticonvulsant or antiepileptic drug), indicated it is used to prevent and control seizures. It works by reducing the spread of seizure activity in the brain. This medication works best when the amount of drug in the body is kept at a constant level. Patients should not stop taking this medication without first consulting with their physician. Seizures can become worse when the drug is suddenly stopped. Review of Resident #2's Medication Administration Record (MAR) for January 18, 2023 through January 23 2023 indicated he/she had physician's orders to be administered Vimpat 100 mg, two times a day, at 9:00 A.M., and 9:00 P.M., however Vimpat was not administered on: -01/18/23 9:00 P.M. -01/19/23 9:00 A.M. and 9:00 P.M. -01/20/23 9:00 A.M. and 9:00 P.M. -01/21/23 9:00 A.M. and 9:00 P.M. -01/22/23 9:00 A.M. and 9:00 P.M. -01/23/23 9:00 A.M. dose. -(ten consecutive doses). Further review of Resident #2's MAR related to the Vimpat indicated nurses documented the following: -Other, see nurse's notes -absence of condition/not applicable. Review of Resident #2's Nurse Progress Notes related to documentation regarding his/her Vimpat medication omission indicated the following: -Nurse Progress Note, dated 01/18/23, indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/19/23, timed 11:19 A.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/19/23, timed 9:08 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/20/23, timed 2:56 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/20/23, timed 10:13 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/21/23, indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/22/23, timed 10:16 A.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated 01/23/23, indicated Resident #2's Vimpat was on order from the pharmacy. Further review of Resident #2's medical record indicated there was no documentation to support that nursing staff notified Resident #2's physician regarding the missed doses of Vimpat, that the physician had been notified it had not been delivered from the pharmacy, or that nursing had contacted the pharmacy to see when the Vimpat would be delivered. The Situation Background Appearance Review and Notify (SBAR) Note, dated 1/23/22, indicated Resident #2 had a change in condition, was stiff and weak, and needed more help with Activities of Daily Living (ADLs). During interview on 02/17/23 at 2:35 P.M., Nurse #4 said she had been assigned to provide care for Resident #2 several times during his/her admission. Nurse #4 said she knew Resident #2's Vimpat was unavailable on several occasions, said she called the pharmacy, was told the Vimpat was going to be delivered, but said she did not notify Resident #2's physician or Nurse Practitioner of the omitted doses. Nurse #4 said that on 01/21/23 another nurse asked her where Resident #2's Vimpat was, so she called the pharmacy again, and was told that the pharmacy had not received the prescription (required) for it. Nurse #4 said she told the other nurse that a prescription was needed, but that she did not call the physician or NP herself, and left the Facility as her shift was over. During interview on 02/13/23 at 2:10 P.M., Nurse #3 said she was assigned to Resident #2 for the first time on 01/23/23. Nurse #3 said Resident #2 was scheduled to be discharged home that day and she noticed his/her Vimpat was unavailable. Nurse #3 said she notified Unit Manager #1 and Resident #2's Hospice Nurse that he/she did not receive Vimpat that day. Nurse #3 said she did not review Resident #2's MAR for the previous days and said she was unaware that Resident #2 had not received 10 consecutive doses of his/her Vimpat. Nurse #3 said Certified Nurse Aide (CNA) #1, who was familiar with Resident #2, told her Resident #2 was different that morning and needed more help with his/her ADLs. During interview on 02/14/23 at 2:22 P.M., Certified Nurse Aide (CNA) #1 said that on 01/23/23 Resident #2 needed more help than usual with ADLs. CNA #1 said Resident #2 was usually able to walk and help with washing, but that day she (CNA #1) needed help from another staff member to transfer him/her. CNA #1 said she found Resident #2 was too weak to walk, needed a wheelchair to move around the room, and was unable to help with washing him/herself. CNA #1 said she notified Nurse #3 of Resident #2's change. During interview on 02/14/23 at 10:58 A.M., Unit Manager #1 said that on 01/18/23, she sent a text message to NP #1 to let her know that Resident #2 was a new admission and needed prescriptions, but did not specifically tell NP #1 that they needed a written prescription sent to the pharmacy for Vimpat, and said she did not see NP #1 after she texted her that day. Unit Manager #1 said she was unaware until 1/23/23 that Resident #2's Vimpat had not arrived from the pharmacy and that there was no prescription written, until right before he/she was discharged from the Facility. During interview on 02/14/23 at 10:58 A.M., Nurse Practitioner (NP) #1 said she was in the Facility on 01/18/23 when Resident #2 was admitted , and said she signed his/her orders, but was unaware that he/she needed a prescription written and sent to the pharmacy for Vimpat. NP #1 said the nurses did not call her any time during his/her admission to notify her of any medication omissions until after Resident #2 had been discharged . NP #1 said she expected that if a medication was not available Nursing would notify the physician or NP and obtain new orders. NP #1 said missing Vimpat put Resident #2 at higher risk for seizure activity and said she would not have discharged him/her home that day as planned. During interview on 2/17/23 at 10:05 A.M., Nurse Practitioner (NP) #2 said she was on call on 01/23/23 and was notified via text message by Unit Manager #1 that Resident #2 was being discharged that day following a five-day respite stay at the Facility, had not received his/her Vimpat that day, and it appeared as though he/she might have had a seizure. NP #2 said she could not recall if she had a phone conversation with nursing regarding Resident #2, and said she was not made aware that he/she had not received 10 consecutive doses of Vimpat. NP #2 said she would have provided orders for and directed nurses to administer another anticonvulsant/antiseizure medication, and would have asked Resident #2's family if they would want him/her transferred to the Hospital for an evaluation. During interview on 02/14/23 at 1:26 P.M., the Director of Nurses (DON) said that nursing staff were expected to notify the physician or NP of any medication omission, but they determined that nurses had not notified the physician or NP of any of Resident #2's omitted medication doses.

Based on records reviewed and interviews, for one of three sampled residents (Resident #2), who was admitted for short term respite care, and whose diagnoses included a seizure disorder, the Facility failed to ensure he/she was free of significant medication error, when he/she was not administered Vimpat, (anticonvulsant medication) 100 milligrams (mg) twice daily, per physician's orders. Resident #2 missed 10 consecutive doses of Vimpat, and although nursing documented it was unavailable, nurses assigned to care for Resident #2 did not notify the physician to report the medication was not being administered or to obtain additional orders related to the omitted doses of Vimpat. On the day of Resident #2's discharge, he/she exhibited signs and symptoms of a change in condition with a decline in status, and nursing reported he/she exhibited signs and symptoms of seizure activity prior to discharge. The Hospice report dated [DATE], indicated Resident #2 had active seizures upon arrival at home that morning. Findings include: The Facility Policy, titled Adverse Consequences and Medication Errors, dated ,d+[DATE], indicated: -A medication error was defined as the preparation or administration of drugs or biological's which was not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principals of the professional providing services. -An Example of a medication error included omission (a drug was ordered but not administered). -In the event of a significant medication related error, immediate action would be taken. Significant was defined as requiring treatment with prescribed medication, resulting in cognitive deterioration or impairment, was life threatening, or resulted in death. -The attending physician would be notified promptly of any significant error, and new orders would be implemented, the resident would be monitored closely, as directed. The Facility Policy, titled, Medication Administration Errors, dated ,d+[DATE], indicated a medication administration error occurred when a resident received a dose of medication that deviated from the original physician's order, and included omission. All medication administration errors may be reported immediately to the physician responsible for the resident and the physician would provide instruction to the nurse regarding the care of the resident as a result of the medication error. Resident #2 was admitted to the Facility in [DATE], diagnoses included epilepsy (seizure disorder), neoplasm (tumor) of the brain, pleural effusion (fluid surrounding the lung), and obstructive uropathy. Review of Resident #2's Medication Review Report, dated [DATE], and signed by Nurse Practitioner (NP) #1 on [DATE], indicated Resident #2 had the following physician's orders: -Vimpat (anticonvulsant, used to treat seizures) tablet, 100 mg by mouth two times a day. Review of WebMD, Uses, Side Effects, and More related to Vimpat (Lacosamide an anticonvulsant or antiepileptic drug), indicated it is used to prevent and control seizures. It works by reducing the spread of seizure activity in the brain. This medication works best when the amount of drug in the body is kept at a constant level. Patients should not stop taking this medication without first consulting with their physician. Seizures can become worse when the drug is suddenly stopped. Review of Resident #2's Medication Administration Record (MAR) for [DATE] through [DATE] indicated he/she had physician's orders to be administered Vimpat 100 mg, two times a day at 9:00 A.M., and 9:00 P.M., however Vimpat was not administered at all during his/her admission, on the following dates and times; -[DATE] 9:00 P.M. -[DATE] 9:00 A.M. and 9:00 P.M. -[DATE] 9:00 A.M. and 9:00 P.M. -[DATE] 9:00 A.M. and 9:00 P.M. -[DATE] 9:00 A.M. and 9:00 P.M. -[DATE] 9:00 A.M. dose. -(ten consecutive doses). Further review of Resident #2's MAR related to the Vimpat indicated nurses documented the following: -Other, see nurse's notes -absence of condition/not applicable. Review of Resident #2's Nurse Progress Notes related to documentation regarding his/her Vimpat medication omission indicated the following: -Nurse Progress Note, dated [DATE], indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], timed 11:19 A.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], timed 9:08 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], timed 2:56 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], timed 10:13 P.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], timed 10:16 A.M., indicated Resident #2's Vimpat was on order from the pharmacy. -Nurse Progress Note, dated [DATE], indicated Resident #2's Vimpat was on order from the pharmacy. Further review of Resident #2's medical record indicated there was no documentation to support that nursing staff contacted and notified Resident #2's physician regarding the missed doses of Vimpat or that nursing had contacted the pharmacy to see when the Vimpat would be delivered. The Situation Background Appearance Review and Notify (SBAR) Note, dated [DATE], indicated Resident #2 had a change in condition, was stiff and weak, and needed more help with Activities of Daily Living (ADLs). The Medication Error Report, dated [DATE], indicated Resident #2 had a physician's order for Vimpat 100 mg by mouth twice daily which was never received from the pharmacy, and nursing staff never reported to the physician or NP that the medication was unavailable. The Facility's Internal Investigation Report, undated, indicated Resident #2 was admitted to the Facility for a five day period (Respite Care), and on the day of admission Nurse Practitioner #1 did not write a prescription (required by the pharmacy in order to dispense) for Vimpat. The Investigation Report indicated that during this time, four nurses (that were assigned to care for him/her) did not administer Resident #2's Vimpat, and all of them assumed there was a delay in receiving it from the pharmacy. During interview on [DATE] at 2:35 P.M., Nurse #4 said she had been assigned to provide care for Resident #2 several times during his/her admission. Nurse #4 said she knew Resident #2's Vimpat was unavailable on several occasions, said she called the pharmacy, was told the Vimpat was going to be delivered, and said she did not notify Resident #2's physician or Nurse Practitioner of the omitted doses. Nurse #4 said that on [DATE] another nurse asked her where Resident #2's Vimpat was, so she called the pharmacy, and was told that the pharmacy had not received the prescription for it. Nurse #4 said she told the other nurse that a prescription was needed, but did not call the physician or NP herself, and left the Facility as her shift was over. During interview on [DATE] at 2:10 P.M., Nurse #3 said she was assigned to Resident #2 for the first time on [DATE]. Nurse #3 said Resident #2 was scheduled to be discharged home that day and she noticed his/her Vimpat was unavailable. Nurse #3 said she notified Unit Manager #1 and Resident #2's Hospice Nurse that he/she did not receive the Vimpat that day. However, Nurse #3 said she did not review Resident #3's MAR for the previous days and said she was unaware that Resident #2 had not received 10 consecutive doses of his/her Vimpat. Nurse #3 said Certified Nurse Aide (CNA) #1, who was familiar with Resident #2, told her Resident #2 was different that morning and needed more help with his/her Activity's of Daily Living (ADLs). During interview on [DATE] at 2:22 P.M., Certified Nurse Aide (CNA )#1 said that on [DATE] Resident #2 needed more help than usual with ADLs. CNA #1 said Resident #2 was usually able to walk and participate with washing, but that day she needed another staff member to help to transfer him/her, CNA #1 said she found Resident #2 was too weak to walk and needed a wheelchair to move around the room, and was unable to help with washing him/herself. CNA #1 said she notified Nurse #3. During interview on [DATE] at 10:58 A.M., Unit Manager #1 said that on [DATE], she sent a text message to NP #1 to let her know that Resident #2 was a new admission and needed prescriptions. Unit Manager #1 said in the text to NP #1 she did not specifically say they needed a prescription for Vimpat, and said she did not see NP # 1 after that on that day. Unit Manager #1 said she was not aware that Resident #2's Vimpat had not arrive from the pharmacy or that there had not been a prescription (required by pharmacy in order to dispense) written until [DATE], right before he/she was discharged from the Facility. Unit Manager #1 said she was notified by Nurse #3 on [DATE] that Resident #2 was weaker than usual, and that he/she might have had a seizure that morning. During interview on [DATE] at 10:58 A.M., Nurse Practitioner (NP) #1 said she was in the Facility on [DATE] when Resident #2 was admitted , and said she signed his/her orders, but was unaware that he/she needed a written prescription sent to the pharmacy for Vimpat. NP #1 said nursing staff did not call her any time during his/her admission to notify her of any medication omissions until after Resident #2 had been discharged home. NP #1 said she expected that if a medication was not available nursing staff would notify the physician or NP and obtain new orders. NP #1 said missing Vimpat put Resident #2 at higher risk for seizure activity, and said she would not have discharged him/her home that day as planned. During interview on [DATE] at 10:05 A.M., Nurse Practitioner (NP) #2 said she was on call on [DATE], and was notified via text message by Unit Manager #1 that Resident #2 was scheduled to be discharged home that day following a five day respite stay at the Facility, had not received his/her Vimpat, and it appeared as though he/she might have had a seizure. NP #2 said she could not recall if she had a phone conversation with staff regarding Resident #2, but said she was not made aware that he/she had not received 10 consecutive doses of Vimpat. NP #2 said she would have provided orders for and instructed nurses to administer an appropriate alternative medication, and would have asked Resident #2's family if they would want him/her transferred to the Hospital for an evaluation. Review of the Hospice Report, dated [DATE], indicated that on [DATE], Resident #1 was discharged home, and assessed as having increased lethargy and weakness, and family reported he/she had an active seizure upon arrival at home. The Hospice Report indicated Resident #2 died early the next morning on [DATE]. During interview on [DATE] at 1:26 P.M., the Director of Nurses (DON) said that nursing staff were expected to notify the physician or NP of any medication omission, but their investigation determined that nursing had not notified the physician or NP of any of Resident #2's omitted Vimpat doses. The DON said if medications were not yet delivered from the pharmacy, nursing staff were expected to check if the medication was available in the Omnicell (automated pharmaceutical dispensing machine), and notify the pharmacy.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as being a risk for falls and required the use of floor mats on either side of his/her bed, the facility failed to ensure staff implemented Resident #1's Plan of Care interventions related to safety, including monitoring for placement of floor mats, Resident #1 fell out of bed, his/her mats were not in place, and Resident #1 sustained a 2 centimeter (cm) laceration to his/her left temporal scalp, was sent to the hospital Emergency department, and was diagnosed with [REDACTED]. Findings include: Resident #1 was admitted to the facility in 6/2015, [DIAGNOSES REDACTED]. Resident #1 admitted to Hospice on 1/15/18. The Fall Risk Assessment, dated 5/28/19, indicated Resident #1 had poor recall, poor judgment, and poor safety awareness. The Fall Risk Assessment indicated Resident #1 was at moderate risk for falls. Review of Resident #1's Physician Orders, dated 6/1/19, indicated he/she required floor mats to be placed on either side of Resident #1's bed when he/she is in bed for safety intervention. Review of the Point Care Kardex (Certified Nurse Aides Care Card) for Resident #1's Safety Plan, indicated fall precautions for Resident #1 included safety mats to floor on either side of Resident #1's bed when he/she was in bed. The Facility's Investigation, dated 6/19/19, indicated that on 6/18/19, at approximately 5:00 P.M., Resident #1 was found in his/her room, on the floor. The Investigation indicated Resident #1 did not have his/her safety floor mats in place on the side of his/her bed at the time of the fall, that he/she sustained a 2 cm laceration to his/her scalp, was sent to the hospital where he/she received six staples to close the wound., and was diagnosed with [REDACTED]. The Investigation indicated CNA #1 forgot to replace the safety floor mats after transferring Resident #1 into bed, prior to him/her being found on the floor. The Surveyor interviewed CNA #1 at 2:06 P.M. on 7/12/19. CNA #1 said on 6/18/19 he transferred Resident #1 into bed and provided care. CNA #1 said he did not place the safety mats on the floor next to Resident #1's bed after he transferred him/her into bed. CNA #1 said he was aware of Resident #1's Plan of Care and said he forgot to place the safety mats by his/her bedside, prior to leaving Resident #1's room. The Surveyor interviewed the Unit Manager at 9:41 A.M. on 7/1/19. The Unit Manager said Resident #1 was found on the floor in his/her room and Resident #1 did not have the safety mat on the floor next to the bed when he/she fell . The Unit Manager said CNA #1, who was taking care of Resident #1, did not place Resident #1's safety mats on the floor next to his/her bed prior to leaving Resident #1's room. The Unit Manager said Resident #1's Plan of Care indicated floor safety mats are required on either side of Resident #1's bed to ensure Resident #1's safety. The Unit Manager said CNA #1 had access to Resident #1's Kardex (Certified Nurse Aides Care Card) which reflects Resident #1's Plan of Care and included safety interventions. Review of Resident #1's Hospital Discharge Summary indicated Resident #1 was diagnosed at the hospital with a left sided pneumothorax due to rib fractures, an underlying collapsed lung and required six staples to close the wound to his/her [MEDICAL CONDITION]. The Facility was found to be in past non-compliance on 7/1/19, the facility provided the Surveyor with a plan of correction which addressed concerns as evidenced by: A) Resident #1 was transferred back to the facility on [DATE] from the hospital and continued on Hospice care. B) The Facility assessed all residents on 6/19/19, 6/20/19 and 6/28/19, who required the use of safety fall mats and staff checked for compliance. C) Resident #1's updated Care Plan, indicated Resident #1 to be out of bed at 4:00 P.M. daily and Resident #1 to sleep on a perimeter mattress. D) The Facility's In-service documentation, dated 6/19/19, indicated nursing was educated on the plan of care needs including fall mats to be followed for every resident, fall interventions and supervision must be provided per the plan of care. E) The Facility's Quality Assurance and Performance Improvement AD H[NAME] Committee Meeting Minutes, dated 6/18/19, that indicated concerns of fall with injury, a resident safety mats not in place and purposeful rounding not being complete to ensure interventions are in place. The documentation indicated the need to ensure the Care Plan and Kardex (Care Card) are being followed by staff on each resident in the facility. The documentation indicated assessing and audit of floor mats, education to be provided to staff and random audits for a timeframe of three weeks. F) The Director of Nurses and/or designee, will be responsible for overall compliance.

Based on observation, interview and record review the Facility failed to define and implement interventions that are consistent with resident needs and recognized standards of practice to prevent a pressure ulcer from developing and to promote healing for 1 resident (#114) in a total sample of 44 residents. Findings include: Resident #114 was admitted to the Facility in 5/2018 with [DIAGNOSES REDACTED]. On 6/19/18 at 9:25 A.M. the Surveyor observed Resident #114 in bed with socks on and heels directly on the mattress. A pair of blue booties were observed on the floor next to the bed. On 6/20/18, at 8:47 A.M. the Surveyor observed Resident #114 in bed with socks on and a pair of blue booties on the dresser next to the bed. On 6/21/18, at 9:05 A.M. the Surveyor observed Resident #114 lying in bed with socks on and a pair of blue booties on the floor next to the bed. On 6/21/18, at 10:48 A.M. the Surveyor observed Resident #114 sitting in a wheelchair with black sneakers on both feet. On 6/25/18, at 9:06 A.M. the Surveyor observed Resident #114 in bed with his/her heels directly on the mattress and a pair of blue booties on the Resident's dresser. On 6/25/18, at 10:30 A.M. the surveyor observed Resident #114 sitting in a wheelchair with black sneakers on both feet. Review of the Skin Evaluation for Resident #114 dated 5/15/18, indicated that there was no skin breakdown on the date of admission and the Resident was at high risk for skin breakdown. Review of Resident 114's care plans, dated 5/15/18, indicated the Resident was at risk for skin breakdown related to impaired mobility and bowel incontinence. Further review of the care plans indicated an intervention to provide preventative skin care routinely but it did not have resident specific interventions related to the [DIAGNOSES REDACTED]. Review of the clinical record failed to indicate that a nutritional assessment was completed prior to the development of the pressure injury to the heel. Further review indicated that in the absence of the nutritional assessment and care plan an order for [REDACTED]. Review of the admission Minimum Data Set assessment ((MDS) dated [DATE], indicated that the Resident required an extensive assist of 2 people to help the Resident reposition him/herself since admission. Further review of the MDS indicated that Resident #114 had a stage 2 pressure ulcer on his/her right heel. Review of the Situtation Background Assessment Report (SBAR) Progress Note dated 5/22/18, indicated that a Stage 2 fluid filled blister was identified on Resident #114's right heel. Review of the doctor's orders dated 5/21/18, indicated an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the care plan dated 5/21/18, indicated a problem titled Actual Skin Breakdown with an intervention for blue boots on both feet when Resident in bed. During an interview on 6/25/18, at 10:45 A.M. Nurse #1 said that the Resident should have had the blue booties on at all times per doctor's order and she would fix that right now. She said that the care plan should follow the doctor's order instead of placing them on just when in bed as the care plan indicated. Nurse #1 also said that the hospice Certified Nurse's Aid (CNA) is the one who gets Resident #114 dressed and up for the day and is the one who put the sneakers on and she was not sure if the CNA was following the care plan and that is why she didn't put the booties on. Nurse #1 then said that the blister had opened and was now crusty and partially scabbed over and she could not tell how deep the wound was.

Based on record review and interview, for 1 of 3 sampled residents (Resident #1), the Facility failed to ensure that Resident #1's bed alarm functioned, per plan of care. On 3/09/12, at approximately 6:15 P.M., Resident #1 got out of bed, fell to the floor, and sustained a fractured right hip and skin tears to the right arm and leg. It was determined that, prior to the fall, the alarm did not activate to alert staff. Findings include: Review of Resident #1's admission Minimum Data Set (MDS) assessment, dated 2/03/12, indicated the following conditions: impaired cognition and disorganized thinking; required extensive staff assistance with transfers and ambulation; unsteady during transitions and walking and was only able to stabilize with human assistance; [DIAGNOSES REDACTED]. Review of Resident #1's plan of care, dated 2/07/12, indicated that he/she was at risk for falls due to a recent history of falls and a recent left hip fracture. Interventions included the use of a bed and chair alarm. Review of Resident #1's physician's orders [REDACTED]. Review of Resident #1's nurse's note, dated 3/09/12 (7:00 A.M. to 3:00 P.M. shift), indicated that his/her bed and chair alarms were in place and working. Review of Resident #1's positioning sheet, dated 3/09/12, indicated that Certified Nurse Aide (CNA) #1 repositioned Resident #1 at approximately 4:00 P.M and 6:00 P.M. Review of Resident #1's nurse's note, dated 3/09/12 (3:00 P.M. to 11:00 P.M. shift), indicated that at 6:15 P.M. Resident #1 fell on to the bathroom floor, located in Resident #1's bedroom. The nurse's note indicated that no one witnessed the fall. The nurse's note indicated that Resident #1 sustained 3 skin tears to the right arm (dimensions not provided) and that he/she complained of pain in the right leg. The nurse's note indicated that Resident #1 was sent to the Hospital for an evaluation. Review of Resident #1's Hospital discharge summary, dated 3/14/12, indicated that on 3/09/12 Resident #1 fell at the Facility, where he/she was receiving physical therapy for a left hip replacement. The summary indicated that, as a result of this most recent fall, Resident #1 sustained a right hip fracture. The Surveyor interviewed Resident #1 on 3/29/12 at 11:50 A.M. Resident #1 said that, on the evening of the incident, he/she got out of bed to use the toilet. Resident #1 said that he/she walked to the bathroom but when he/she looked inside the bathroom there was feces on the toilet and the floor. Resident #1 said that he/she turned away from the bathroom to walk back toward the bed and he/she fell to the floor. Resident # 1 said that his/her right side fell against a wall and then to the floor (Resident #1 showed the Surveyor healing abrasions on the right arm). Resident #1 said that he/she was bleeding and his/her right leg hurt. Resident #1 said that CNA #2 arrived at the bedroom and then other staff responded to the incident. Resident #1 said that, when he/she got out of bed to use the toilet, he/she did not hear the bed alarm sounding. Resident #1 said that he/she was unaware that the bed alarm was unplugged. Resident #1 said that he/she did not unplug the alarm and that he/she did not know where the plug was located, or how to unplug the alarm. Resident #1 said that he/she was not aware of the location of the bed alarm. The Surveyor interviewed the Director of Nurses (DON) on 3/29/12 at 8:50 A.M. The DON said according to staff interviews, it was determined that Resident #1's bed alarm did not sound when Resident #1 got out of bed to use the toilet. The DON said that she believed the alarm was unplugged, but she did not know who unplugged the alarm.