Every finding on record at Maple Heights

Based on observation, interview and record review, the facility failed to ensure that staff safely stored controlled substances under double lock for 4 of 46 residents reviewed. The facility reported a census of 46 residents. Findings include: On 12/16/2025 at 8:06 AM, during an observation of the medication pass, it was discovered that several residents had controlled drugs (Ativan and Clonazepam) in the drawer with the rest of the scheduled medications. Staff C, Licensed Practical Nurse (LPN), said that they kept the scheduled doses of Ativan and Clonazepam with all the other medications and they did not have narcotic sheets to monitor daily count. On 12/16/2025 at 3:06 PM, Staff B, Registered Nurse (RN) said that they did not keep a narcotic sheet for scheduled Ativan or Clonazepam but they do keep them for the As Needed (PRN) doses. 1) According to the Minimum Data Set (MDS) dated [DATE] Resident #49 was admitted to the physically on 11/25/25 with diagnose that included: [NAME], renal insufficiency, anxiety disorder, depression and psychotic disorder.The Medication Administration Record (MAR) for Resident #49 showed an order dated 11/25/25 at 7:00 PM for clonazepam 1 milligram (mg) one time a day related to insomnia.The medication cart included a cassette of clonazepam, 1 mg tabs that were not double locked. 2) The MDS dated [DATE], showed that Resident #45 was admitted to the facility on [DATE] with diagnosis that included: diabetes mellitus, Alzheimer's Disease, anxiety disorder and depression.The MAR showed the following orders for Resident #45: a. 12/13/25 at 4:00 PM, Ativan 0.5 mg afternoon dose. b. 11/21/25 at 6:00 AM, Ativan 0.5 mg morning dosec. 8/22/25 at 7:00 PM, Clonazepam 0.5 mg 1 tab twice a day.The medication cart included a cassette of Ativan and a cassette of Clonazepam pills for Resident #45 that were not double locked.3) According to the Minimum Data Set (MDS) dated [DATE], Resident #7 was on high-risk drugs, including: antipsychotic, antianxiety and antidepressant.The MAR showed an order dated 10/9/25 at 7:00 PM, for Ativan 1 mg. tab twice a day.The medication cart included one cassette of Ativan pills for Resident #7 that was not double locked.4) According to the MDS dated [DATE], Resident #11 was admitted on [DATE]. She had diagnoses that included: Alzheimer's Disease, anxiety disorder and depression. The MAR for Resident #11 showed an order dated 8/9/25 at 11:00 AM, for Ativan 0.5 mg one tab daily.The medication cart included one cassette of Ativan for Resident #11 that was not under double lock.On 12/16/2025 at 3:07 PM, the Director of Nursing (DON) said that they were counting, double locking and double documenting the PRN controlled substances but not the Ativan or Clonazepam. She said that the pharmacy sends a 14 day supply of the scheduled doses so they keep close track of them. The DON said that they did not have a policy on storage of controlled substances. On 12/17/25 at 2:16 PM, the DON said they have orientation with the nurses and Certified Medication Aides regarding the storage and counting of medications.

Based on observations, clinical record review, staff interviews, and policy review the facility failed to use universal infection control measures (hand hygiene), and Enhanced Barrier Precautions (EBP) during catheter/wound care for 2 of 5 residents (Resident #5, and #20) reviewed. The facility further failed to monitor for the growth of legionella. The facility reported a census of 46 residents. Findings include:1. Review of Resident #20's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognition. The MDS further revealed diagnoses of heart failure, renal insufficiency, diabetes mellitus, and a stage 2 pressure ulcer of an unspecified site. Review of Resident #20's Electronic Healthcare Record (EHR) page titled, Clinical Physician's Orders revealed a physician order to wash Resident #20's left heel, pat dry, apply honey to wound bed, and then cover with dry gauze with a start date of 9/18/25. Review of Resident #20's Care Plan with a revision date of 12/9/25 revealed Resident #20 had an intervention of EBP related to wounds with a date initiated 3/5/25. Observation on 12/17/2025 at 9:11 AM with Staff E Licensed Practical Nurse (LPN), the nurse completed hand hygiene and donned gloves to remove Resident #20's old dressing to the left heel. Staff E then did not complete hand hygiene prior to donning new gloves. Staff E then completed the treatment to Resident #20's left heel. Staff E then doffed her gloves and completed hand hygiene. Staff E then donned new gloves and then applied the new dressing to the area. Staff E then doffed gloves and completed hand hygiene. No gown was donned during treatment. Interview on 12/17/2025 at 9:18 AM with Staff E LPN revealed that she should have wore a gown for the dressing change for Resident #20, and should have completed hand hygiene after taking the old dressing off and putting new gloves on. 2. Interview on 12/16/2025 at 9:57 AM with Staff F Maintenance revealed that he does check water temps weekly, but has gotten lax about documenting the temperatures. Staff F then revealed the facility does have back flow valves, and rooms are flushed weekly by housekeeping. Staff F then confirmed that water temperatures had not been being documented regularly since April of 2024. Review of facility provided documents titled, Weekly Hot Water Temperature Log for the months of February through December of 2024 revealed no weekly temperatures were recorded since April of 2024. Interview on 12/16/2025 at 10:24 AM with the Administrator revealed that the facility does have a legionella policy with water mapping. The Administrator then revealed that water temps should be being completed and documented. Review of a facility provided policy titled, Water Management Program with a review date of 1/2025 revealed: a. Staff that is hired in each department is orientated to the safe operation of the equipment. They are also trained in how to report any faulty equipment along with the temperatures they are to operate at. Records are kept in respective areas to make sure we are protecting the integrity of the water. 3) The MDS for Resident #5, dated 10/28/25, showed that he had a BIMS score of 15 (intact cognitive ability.) He was independent with eating, hygiene, dressing and transferring and he had an indwelling urinary catheter. His diagnoses included benign prostatic hyperplasia (BPH), renal insufficiency and obstructive uropathy. The Care Plan updated on 2/24/25, showed that Resident #5 needed assistance with some Activities of Daily Living (ADL's), was independent with toileting and related hygiene, however, he needed assistance with managing his urinary catheter. He had a Foley catheter due to urinary retention; staff were to assist with catheter cares and to use enhanced barrier precautions (gown and gloves) related to indwelling catheter. Use catheter extension tubing to reduce irritation. On 12/16/25 at 6:48 AM, Resident #5 was in his wheel chair and he propelled himself out of his room. He said that he needed someone to put on the extension for his catheter because it was pulling on him. At 6:57 AM, Staff D, Certified Nurse Aide (CNA), went in, the room to assist. She applied disposable gloves but failed to put on a gown before she applied the catheter extension. Interview on 12/17/2025 at 9:24 AM with the Director of Nursing (DON) revealed that her expectation would be for staff to complete hand hygiene, and glove changes at the appropriate times during wound cares. The DON further revealed that she would expect staff to wear the proper EBP during wound care for residents with EBP. Review of a facility provided policy titled, Hand-Washing Technique with a date of 2/5/22 revealed: a. Hands should be washed after close resident contact even when gloves are worn. Review of another facility provided policy titled, Enhanced Barrier Precautions with an updated date of 8/26/25 revealed: a. Gowns and gloves will be worn while providing high contact care activities: 1. Device care 2. Wound care

Based on observation, resident and staff interviews, and record review the facility failed to provide increased monitoring and assessment with medication changes for 1 of 1 resident reviewed. Resident #7 had many changes to her psychotropic medications in July, and the staff failed to increase monitoring and failed to conduct an AIMS assessment (Abnormal Involuntary Movement Scale, used to monitor side effects from psychotropic medications.) The facility reported a census of 46 residents. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #7 had a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive deficits.) The resident was independent with eating, hygiene, and transfers and she was on high-risk drugs, including: antipsychotic, antianxiety and antidepressant. The Care Plan updated on 12/9/25, showed that Resident #7 had impaired cognitive function and impaired thought process. Staff were to administer medications as ordered and monitor for side effects and effectiveness. She was at risk for adverse reaction related to psychotropic medications, staff were directed to observe for adverse effect and to report to the physician, increased irritability, lethargy, blurred vision, and nausea/vomiting.On 12/17/2025 at 7:35 AM, Resident #7 was in a recliner in her room. She had her hand on her chest and said she didn't feel well. She said that the staff told her that she had to come out for breakfast and she always ate breakfast in her room She said she didn't feel well and her legs hurt. When asked if the nurse had talked to her about how she was feeling and she responded that no one cared about her.The following documentation was found in the Nursing Progress Notes:a. On 7/22/25 at 3:06 PM, Resident #7 had new medication orders: 1. Lexapro (Selective Serotonin Reuptake Inhibitor, SSRI) 5 milligrams (mg) decrease to one tab daily for 1 week then one tab every 3 days for 1 week then stop 2. Start mirtazapine (antidepressant) 7.5 mg one tab at night for anxiety 3. Decrease midodrine (blood pressure medication) 2.5 mg to BID for one week then daily for 1 week then stop. 4. Monitor BP BID for 3 weeks and report to provider. 5. Ativan (antianxiety) 0.5 mg decrease to one half tab BID for 2 weeks then half tab at night for 2 weeks then stop.b. From 7/23 - 7/26, the chart lacked any nursing progress notes.c. On 7/26/25 at 8:42 PM, Resident #7 reported having vivid dreams and she wasn't sure she wanted to take her night time pills.d. From 7/26 - 7/29, the chart lacked nursing notes.e. On 7/29/25 at 10:48 AM, the facility received a phone call from the resident's daughter who said that that resident was reporting nightmares and not feeling well. New order received to discontinue the mirtazapine and start buspirone 5mg three times a day for anxiety. f. On 7/29/25 at 1:48 PM, a new order received to discontinue melatonin.g. From 7/29/25 - 8/1/25, the nursing progress notes included reference to daily weight communication, Physical Therapy and Occupational Therapy plans to discharge due to max benefits but lacked reference to the resident's current condition. From 7/29/25 - 8/6/25 the progress notes lacked documentation of the resident's response to medication changes.h. From 7/29 - 8/6, the vitals tab lacked any heart rate, respiratory assessment or temperature. i. On 8/6/25 at 6:18 PM, Resident #7 reported shortness of breath and said she hadn't felt well all day. She was then transferred to the hospital.j. On 8/6/25 at 9:44 PM, the facility received a report from the hospital that Resident #7 was found to have a pulmonary embolism.On 12/17/2025 at 10:11 AM, Staff A, Licenses Practical Nurse (LPN), and Staff C, LPN said that they didn't have any specific form or directives to increase monitoring when a resident was put on a new medication but it would depend on the medication. They said they did not remember any changes in Resident #7 after the many mental health medication changes.On 12/17/2025 at 8:37 AM, the Director of Nursing (DON) said that they didn't necessarily have a standard form or specific required documentation for extra monitoring of a resident when they have a medication change. She said that Resident #7 had been on their radar and the nurses were watching for changes, but they didn't necessarily document it. According to the National Library of Medicine article titled: Switching and Stopping Antidepressants, retrieved on 12/18/25 at 2:40 PM from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4919171/pdf/austprescr-39-076.pdfAntidepressant switches must be carried out cautiously and under close observation. Withdrawal symptoms generally begin within hours to days of dose reduction. Withdrawal from SSRI tends to cause flu like symptoms, nausea, lethargy, dizziness anxiety, insomnia and vivid dreams.According to nurse education undated and titled: Anti-anxiety and Anti psychotropic Medications. When an antipsychotic medication was ordered, staff were to complete the AIMS scale. This assessment may also need to be done when there was an increase in dose.

Based on clinical record review, resident interview, staff interview, and policy review the facility failed to assess residents for safety while smoking for 2 of 2 residents reviewed (Resident #13, and #14). The facility reported a census of 46 residents. Findings include: 1. Review of Resident #13's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, and nicotine dependence. Interview on 12/15/2025 at 11:41 AM with Resident #13 revealed that she does smoke. Resident #13 then revealed that she has had no issues while smoking at the facility. Review of a facility provided document titled, Safe Smoking Evaluation with an observation on 7/2/24 revealed this was the last safe smoking evaluation completed for Resident #13. 2. Review of Resident #14's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed diagnoses of coronary artery disease, heart failure, diabetes mellitus, and chronic obstructive pulmonary disease.Interview on 12/15/2025 at 12:02 PM with Resident #14 revealed that she is a smoker at the facility.Review of the Electronic Healthcare Record (EHR) page titled, Smoking Safety Evaluation dated 2/10/25 revealed the assessment was to be completed quarterly, and this was the last assessment completed. Interview on 12/16/2025 at 8:34 AM with the Director of Nursing (DON) revealed that smoking assessments should be completed every quarter to evaluate for safe smoking. The DON confirmed that the last smoking assessment for Resident #13 was completed on 7/2/24, and the last assessment completed for Resident #14 was 2/10/25.Interview on 12/16/2025 at 10:44 AM during a follow up interview with the DON revealed that the facility follows the standards of practice for completing smoking assessments at the appropriate times as the facility does not have a policy as to when smoking assessments should be completed.

Based on electronic record review (EHR), staff interview, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or approaches for the implementation of Enhanced Barrier Precautions for 1 of 3 residents reviewed (Resident #26). The facility reported a census of 49 residents. Findings include: Review of Resident #26's Minimum Data Set (MDS) dated [DATE] revealed Resident #26 was admitted to the facility on [DATE] from a short term hospital stay. The MDS further revealed that Resident #26 utilized the use of an indwelling catheter. Review of a document titled, Order Summary Report revealed a physician's order for a 16 french indwelling Foley catheter to be changed on the 15th of every month in the evening starting on the 15th and ending on the 15th every month for catheter change. This document further revealed that this order had an order dated of 1/8/25 and a start date of 1/15/25. Review of a document titled, Baseline Care Plan with a signed date of 2/7/25 revealed that Resident #26 does utilize an indwelling catheter. The Care Plan lacked staff directive to use Enhanced Barrier Precautions. During an interview on 2/11/25 at 2:52 PM with the Director of Nursing (DON) revealed the facility did not have a policy on accuracy of care plans. The DON further revealed the facility followed professional standards, and the Resident Assessment Instrument (RAI) when care plans are completed.

Based on observation, staff interviews, and policy review the facility failed to properly secure and store medications to minimize loss or access for 1 of 1 medication carts. The facility reported a census of 49 residents. Findings include: During a continuous observation 2/10/25 at 2:20 PM the medication (med) cart on the east hall of the facility was left unlocked and unattended for 5 minutes by Staff C Licensed Practical Nurse (LPN). In this time a Resident (Resident #29) at the facility rolled by in a wheelchair past the unlocked medication cart. At 2:25 PM Staff D Registered Nurse (RN) came from the south hallway and came to the unlocked med cart and locked it. Interview 2/10/25 at 2:36 PM with Staff E RN revealed the med cart should be locked when not working with it. Interview 2/10/25 at 3:31 PM with the Director of Nursing (DON) revealed that the facility's expectation would be for med carts to be locked when not in use or out of eyesight of the nurse using it. The DON further revealed that the facility does not have a policy for this as the facility follows standards of practice.

Based on observations, staff interviews and clinical record review the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of pathogens for 3 of 3 residents reviewed. (Residents #103, #47 and #26.) Residents #103 and #47 required enteral nutrition and medication administration (directly into the gastrointestinal tract through feeding tube.) Resident #26 had a urinary catheter. Staff failed to wear all of the required Personal Protective Equipment (PPE) when administering cares to these three residents. The Facility reported a census of 49 residents. Findings include: 1) According to the Baseline Care Plan dated 2/5/25 at 3:28 PM, Resident #103 required special treatments including suctioning, tube feedings and a suprapubic catheter. The resident was non-verbal and did not understand staff. An order dated 2/5/25 at 1:31 PM, showed that Resident #103 had continuous nutrition through enteral feedings. 2) The Profile page for Resident #47, showed special instructions for staff to use Enhanced Barrier Precautions. (infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) An order dated 2/10/25 at 6:44 PM, showed that all medications for Resident #47 should be administered via PEG (Percutaneous Endoscopic Gastrostomy, used for long-term enteral feeding) tube. The Care Plan updated on 1/20/25, showed that Resident #47 had severe limited physical mobility related to cerebral palsy and was totally dependent on staff for all Activities of Daily Living. The residents' main source of nutritional intake was through PEG tube feedings. On 2/11/25 from 9:13-9:30 AM, Staff A Licensed Practical Nurse (LPN) provided medication administration and enteral feeding set-up via Kangaroo Pump (used to deliver enteral nutrition and hydration.) Residents #103 and #47 resided in the same room. Staff A failed to wear a gown throughout the process. On 2/13/25 at 9:00 AM, the Director of Nursing (DON) acknowledged that staff were expected to use EBP when administering tube feedings and medications through the PEG tube. 48004 3. Review of Resident #26's MDS dated [DATE] revealed Resident #26 requires the use of an indwelling catheter. The MDS further revealed that Resident #26 has a diagnosis of chronic kidney disease. Review of a document titled, Order Summary Report revealed a physician's order for a 16 french indwelling Foley catheter to be changed on the 15th of every month in the evening starting on the 15th and ending on the 15th every month for catheter change. This document further revealed that this order had an order dated of 1/8/25 and a start date of 1/15/25. On 2/11/25 at 9:51 AM observed Staff E Certified Nurses Aide (CNA) and Staff F CNA complete hand hygiene and donn gloves. Staff E and Staff F then proceeded to drain Resident #26's catheter drainage bag. Hand hygiene was completed after the procedure. No gown was worn during the process. Interview on 2/11/25 at 10:03 AM Staff F revealed that she and Staff E should have worn gowns during catheter drainage for Resident #26 as this is part of Enhanced Barrier Precautions. Interview on 2/11/25 at 2:52 PM with the Director of Nursing (DON) stated the facility's expectation was for Personal Protective Equipment (PPE) to be worn appropriately when caring for residents with enhanced barrier precautions in place. Review of a facility provided policy titled, Enhanced Barrier Precautions with a date of 7/2022 and updated date of 3/21/24 revealed: EBP should be applied to residents with any of the following: 1. Chronic wounds 2. Indwelling medical devices, regardless of MDRO (Multi-drug resistant organisms) colonization status. (Indwelling device examples include central/PICC lines, urinary catheters, feeding tubes and tracheostomies).

Based on observation, interviews and policy review the facility failed to ensure that all food items were replaced before the recommended past due date. On 5/6/24 it was discovered that a bin of flour had an open date of October of 2023. The facility reported a census of 37 residents. Findings include: During an observation of the facility kitchen on 5/6/24 at 9:25 AM it was discovered that on the lid on a bin of flour, there was a piece of brown tape with a date of 10/16/23. The Certified Dietary Manager (CDM) said that would have been the date that the bin was last filled with flour. She was not sure of the recommended shelf life for flour. On 5/7/24 at 10:15 AM, the CDM said that she talked to the dietician about the flour and was told that in those containers, the flour would be good for 6 months. The CDM said that she had emptied the flour bin and cleaned it out and would refill it with fresh flour. On 5/8/24 at 2:30 PM, the facility Dietician said that she expected the staff to date the items when they are first opened. The flour should not be kept in the bin for more than 6 months. An undated policy titled: Safety in Food Products and Storage, indicated that all food products would be rotated.

Based on observation and staff interview the facility failed to provide appropriate infection prevention practices when securing a catheter drainage bag to a trash can for 1 of 1 residents reviewed (Resident #33).The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #33 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS documented Resident #33 had an indwelling catheter. On 5/6/24 at 10:31 AM an observation of Resident #33's catheter bag hanging on her garbage can, with trash in the garbage can. Resident #33's catheter bag lacked a dignity cover. On 5/8/24 at 12:25 PM Staff A, Certified Nursing Assistant (CNA) stated [catheter] either laying on a barrier on the floor or hanging from Resident #33 garbage can. Stated dignity bags are not utilized in the residents room. On 5/8/24 at 12:36 PM the Director of Nursing (DON) stated the facility's expectation is that it [catheter] would be placed on a barrier on the ground. The DON stated she would not expect the catheter bag to be hanging on the garbage can. The DON stated the facility had no policy on catheter placement. The DON stated the facility follows professional standards of practice.

Based on Electronic Record Review (EHR), document review, and staff interviews the facility failed to provide a Comprehensive Care Plan including goals and interventions for pain, with the use of opioids for 1of 5 residents reviewed (Resident #7). The facility reported a census of 37 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #7 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. MDS revealed a diagnosis of pain. Review of Resident #7 Physician Orders documented an order for Tramadol 50mg PRN every 6 hours with a start date of 12/23/22. Review of Resident #7 Care Plan revealed a lack of goals with interventions related to pain, and the use of opioids. On 5/8/24 at 3:25 PM the DON (Director of Nursing) stated the facility's expectation was Resident #7 ' s Care Plan would have goals and interventions in place for pain with the use of opiods. The DON stated the goals and interventions were not present in the Care Plan for Resident #7. The DON stated the facility has no policy for Care Plans. The DON stated the facility follows the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) for Care Plan completion.

Based on clinicial record review, and staff interviews the facility failed to update the Care Plan when a resident had a change in condition for 1 of 15 residents. Resident #35 experienced some increased weakness, loss of appetite and was diagnosed with the COVID-19 virus. The Care Plan lacked interventions or increased monitoring related to the residents needs. The facility reported a census of 37 residents Findings include: According to the Minimum Data Set (MDS), dated [DATE], Resident #35 had a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating a severely impaired cognition. Diagnosis included heart failure, non-Alzheimer's Dementia, malnutrition, and retention of urine. The Physician Order's for Resident #35 included an order dated 11/6/23 for COVID-19 screening as needed. A Nursing Note, dated 2/3/24 at 8:16 AM, revealed the resident reported not feeling well that morning and presented with nasal congestion, shortness of breath and a sore throat. Staff administered a COVID-19 test, and the residetn tested postive. The Care Plan included a note dated 2/3/24 indicating the resident was started on an antibiotic and steroid for COVID-19, but lacked direction to staff on interventions or monitoring goals. On 5/9/24 at 7:48 AM, The Director of Nursing (DON) stated the facilty did not have a specific policy related to Care Plan updates and follow the standards of care.

Based on electronic record review, document review, and staff interview the facility failed to develop and implement policies and procedures, to ensure a resident's medical record included documentation that a resident refused the influenza or pneumococcal immunizations for 1 of 5 residents reviewed (Resident #27). The facility reported a census of 36 residents. Findings included: The Minimum Data Set (MDS) for Resident #27 documented she entered the facility on 5/26/21. The MDS also documented a Brief Interview of Mental Status (BIMS) of 3, indicating severe cognitive impairment. In an interview on 2/21/23 at 11:26 AM, Staff F, Licensed Practical Nurse (LPN), stated on the day of admission residents are offered vaccines and their history of vaccines are discussed. Staff F explained that the chart had notes about vaccines in the nurses notes on the day of admission as well. The electronic and paper record review conducted on 2/21/23 at 1:30 PM revealed Resident #27 did not have documentation of a declination of the COVID-19 immunization. In an interview on 2/21/23 at 11:15 AM, Staff H, Director of Nursing (DON), verified that Resident #27 did not have a declination of immunization completed. Staff H stated Resident #27 refuses all immunizations. Staff H reported that the facility's expectation is that a declination form is filled out or charted in medical records for any immunizations that are declined or refused by residents.

Based on observations, interviews, and record review the facility failed to implement adequate infection control measures to prevent the spread of infection. On three separate observations the staff failed to use the recommended Personal Protective Equipment (PPE) and social distancing when interacting with residents that were positive for Covid-19. The facility reported a census of 36 residents. Findings include: 1. On 2/20/23 at 12:40 PM, observed that room [ROOM NUMBER] had contact precaution signage on the door frame. At the time witnessed Staff D, Licensed Practical Nurse (LPN), in the room with Resident #15 trying to calm them during a coughing spell. The observation revealed Resident #15's room door open and Staff D not wearing a gown or gloves. She held a package of disposable gowns. When she left the room, she went to a cart at the end of the hall, without hand hygiene, she opened a drawer on the cart and put the gowns in the drawer. Without completing hand hygiene, she then donned a gown and gloves before she helped the resident and closed the door. According to the census report, Resident #15 resided in that room and she tested positive for COVID-19 on 2/13/23. 2. On 2/20/23 at 11:07 AM, observed that room [ROOM NUMBER] had contact precaution signage outside the door. Resident #1 sat in a wheelchair just inside their room with her door open. Staff I, Housekeeping, stopped in the doorway and visited with the resident for a couple of minutes. The staff member wore a surgical mask and no gloves. As she talked to the resident, Staff I rested her bare hand on the doorframe and the two of them were just a couple of feet apart. Staff I then proceeded down the hallway and failed to use hand sanitizer. According to the census report Resident #1 resided in that room and she had tested positive for Covid-19 on 2/13/23. 44420 3. The Minimum Data Set (MDS) dated [DATE] for Resident #29, identified a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Care Plan last revised on 2/21/23 revealed Resident #29 tested positive for COVID-19 on 2/12/23. The Care Plan instructed staff to wear personal protective equipment (PPE) when entering his room. On 2/21/23 at 9:27 AM observed a sign posted outside of Resident #29's room that instructed the staff to apply PPE before entering his room, including a N95 mask. On 2/20/23 at 1:43 PM watched Staff D, Certified Nurse Assistant (CNA), entered Resident #37's wearing personal protective equipment (PPE) of a surgical mask, face shield, gown, and gloves for transmission based droplet precautions related to COVID-19. Staff C assisted Resident #29 with a transfer from the wheelchair to their recliner using an EZ Stand. After exiting the resident's room, Staff C stated, I was told that I didn't have to wear a N95 in COVID positive rooms because I just got over COVID last week. In an interview on 2/21/23 at 5:17 PM, the Director of Nursing reported that she expected staff to wear PPE and a N95 mask, not a surgical mask, when staff entered a resident's room that is infected with COVID-19. The Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last updated Sept. 23, 2022, revealed Health Care Personnel are required to wear a N95 mask or higher respirator during care of a resident infected with COVID-19.

Based on clinical record review and staff interview the facility failed to limit the timeframe for PRN (as needed) a psychotropic medication to 14 days, unless the physician deemed a longer timeframe appropriate, for 1 of 5 residents reviewed for unnecessary medications (Resident #30). The facility reported a census of 36 residents. Findings Included: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #30 identified a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #30 had a PHQ-9 (9-question depression scale of PHQ) score of 21, indicating severe depression. The MDS included diagnoses of non-Alzheimer's dementia, restlessness, and agitation. Resident #30 used antianxiety and antidepressant medications for seven out of seven days in the lookback period. The Physician's Order List included the following psychotropic medications: a. Start date of 1/20/22 without a stop date: Ativan 0.5 mg tablet ordered every 4 hours as needed (PRN) for agitation and restlessness. The Medication Administration Records (MAR) for Resident #30 showed the administration dates for Ativan 0.5 mg tablet ordered every 4 hours PRN for agitation and restlessness: a. January 24, 2022 b. February 8, 2022 c. February 9, 2022 d. March 31, 2022 e. April 31, 2022 f. June 4, 2022 g. July 4, 2022 h. August 15, 2022 i. October 8, 2022 j. November 16, 2022 k. December 17, 2022 l. January 14, 2023 The Care Plan reviewed on 2/21/22 at 9:53 AM for Resident #30 showed the facility failed to monitor the resident's usage and side effects to watch for psychotic medication usage. In an interview on 2/22/23 at 1:45 PM, the Director of Nursing (DON), reported that she knew about the psychotropic medication PRN requirement. The DON reported that she taught the staff that PRN psychotropic medications required a 14 day stop date otherwise a written review is required by the physician. In an interview on 2/22/23 at 2:11 PM, the DON acknowledged that the facility failed to limit the PRN Ativan order to 14 days and that the facility lacked a documented rationale by the prescribing physician for the PRN Ativan order that extended beyond 14 days. The DON stated, I know we should be doing that, but we didn't for this one. The DON reported that the facility lacked a policy for psychotropic medications.

Based on observation, interview and record review the facility failed to implement safe transfer practices to prevent accidents and hazards for 1 of 3 residents reviewed (Resident #7). As the staff transferred Resident #7 with the use of a sit to stand mechanical lift, he could not hold onto the left handle, and the sling supported most of his weight. The facility reported a census of 36 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #7 had a Brief Interview for Mental Status (BIMS) score of 9 (moderate cognitive deficit). The resident required extensive assistance with the help of one staff member for transfers, dressing and toilet use. The MDS included diagnoses of hemiplegia affecting the left side, aphasia, contracture of the left hand, and contracture of the left ankle. The Care Plan dated 10/4/22 showed that Resident #7 needed assistance with Activities of Daily Living (ADL) due to left-sided paralysis. He required extensive assistance with transfers and toilet use. The Care Plan instructed the staff to use the EZ lift mechanical lift. The paper copy of the care plan had the word lift crossed out and stand was added. The written changes did not include a date. On 2/19/23 an addition was made that indicated that the resident had tested positive for the COVID-19 virus. In an observation on 2/20/23 at 12:52 PM Staff A, Certified Nursing Assistant (CNA), moved the sit to stand mechanical lift into the room of Resident #7. She assisted the resident to put his feet on the platform. After getting his feet on the platform, his left foot did not lay flat and his toes were up on the rim of the platform. The resident wore a lower leg brace on his left leg. Staff A failed to strap his legs onto the stand for support and his shins did not rest against the shin padding. The resident moaned as she raised him up out of the chair and pushed him to the bathroom. The resident's left arm hung over the side of the sling, and the sling was up into his armpits. The sling supported a majority of his weight as evidenced by his slumped body and the sling that slid higher up his arm as staff transferred him. On 2/21/23 at 8:32 AM, Staff J, Physical Therapist (PT), reported being familiar with Resident #7 and knew that he had left-sided weakness but it had been several months since PT worked with him. She said at that time he could walk but he mostly dragged his left leg behind him. She said that if he wasn't bearing weight on the stand, the staff should not be using the EZ stand but should use the EZ lift. On 2/21/23 at 9:07 AM Staff C, CNA, said that at times Resident #7 would not bear weight on his legs as he should in order to use the EZ stand. She said he could no longer walk because his right knee would give out. She explained that she would always strap his legs on the EZ stand when transferring with the mechanical lift because he could be unstable. On 2/21/23 at 5:32 PM, the Director of Nursing (DON) said that Resident #7 went back and forth on his level of ability related to use of EZ lift or stand. She said that nursing should evaluate him for mechanical lift use if he had a decline in ability. On 2/22/23 at 10:46 AM, Staff A said that Resident #7 had his good and bad days. Some days he would have a lot of pain in his hips and then he would be unable to bear weight on either side. She said that sometimes the resident would take his right hand and hold his left arm while they transferred him, therefore, he would not be holding onto either handle. She said that she would use the lift rather than the stand if he wasn't bearing weight on his legs. According to the EZ Way Stand owner's manual dated 2007, page 2 instructed staff to apply the harness 4-5 inches below the underarm, place the feet on footplate, and position shins into shin pads. If necessary to keep patients shins or feet on foot plates, secure shin straps around the legs. Page 3 instructed staff to place the patients' hands on the padded handles. On 2/23/23 at 7:48 AM, the DON said that she knew Resident #7 had moments of instability on his feet and she would expect the staff to strap his legs into the sit to stand when transferring him.

Based on clinical record review, staff interview, and facility policy review, the facility failed to develop Care Plans to address psychotropic medication usage, opioid medication, pain management, elopement risk, and dementia for 4 out of 14 residents reviewed (Residents #3, #10, #30, and #140). The facility reported a census of 36. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #30 identified a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Resident #30 had a PHQ-9 (9-question depression scale of PHQ) score of 21, indicating severe depression. The MDS included diagnoses of non-Alzheimer's dementia, restlessness, and agitation. Resident #30 used antianxiety and antidepressant medications for seven out of seven days in the lookback period. The Physician's Order List included the following psychotropic medications: a. 9/15/22 Ativan 0.5 milligrams (mg) tablet ordered twice a day at noon and bedtime. b. 1/20/22 Ativan 0.5 mg tablet ordered every 4 hours as needed (PRN) for agitation and restlessness. Interdisciplinary Notes Review 2/6/23 at 10:53 AM - At the beginning of the shift, Resident #30 paced and attempted to exit the building out the back door as another staff member left. The staff redirected Resident #30 and he continued to walk around the building multiple times asking what he could or should be doing. 2/13/23 at 5:22 AM - As Resident #30 wandered in the hallway, he entered room [ROOM NUMBER] and scared the resident in that room. It took two staff members to redirect him back into his room to get dressed. Resident #30 got back up and across the hall attempting to go into room [ROOM NUMBER] again. 2/21/23 at 6:37 AM - At 5:30 am this morning a Certified Nursing Assistant (CNA) reported that Resident #30 roamed the halls. The Care Plan reviewed on 2/21/22 at 9:53 AM for Resident #30 showed the facility failed to monitor the resident's usage and side effects to watch for psychotic medication usage. The Care Plan also lacked documentation for the facility to safely monitor Resident #30's wandering and exit seeking behaviors to prevent a possible elopement. In an interview on 2/21/23 at 2:11 PM, the Director of Nursing (DON) revealed that she expected psychotropic medication, usage, and side effects to be on the care plan. In an interview on 2/21/23 at 6:07 PM, Staff K, CNA, reported that he observed Resident #30 wander into other resident rooms on occasion. Staff K stated, I only know of a couple of times he has tried to get outside but we were there and he is easily redirected. In an interview on 2/22/23 at 11:42 PM, the DON reported that she added psychotropic medications to Resident #30's Care Plan. When asked about Residents #30's elopement and wandering risk she responded, we don't have a locked unit. We would also talk with family about different placements but he doesn't really wander and doesn't seek. The DON reported the facility lacked a psychotropic medication and Care Plan policy. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #140 identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated cognition intact. The MDS showed Resident #140 prescribed opioids. The MDS diagnosis showed post shoulder surgery, fractures or other trauma and polyneuropathy. In an interview on 2/20/23 at 1:31 PM, Resident #140 reported that she had severe pain in her right hand and shoulder area at times due to a recent fall that required shoulder surgery. Resident #140 observed with a shoulder immobilizer applied to her right shoulder. Resident #140 reported she is prescribed regular pain medication and could have extra pain medication and ice packs if needed. Resident #140 stated, the pain can get severe sometimes, right now it happens more in her right hand. Resident #140 stated that she didn't know when asked if the pain medication and packs worked for her. The Physician's Order List Review included the following pain medications: a. Acetaminophen 325 mg 2 tabs every 4 hours PRN for pain. b. Tramadol 50 mg twice a day PRN for pain. c. Tramadol 40 mg 3 times a day for pain. d. Physical Therapy for pain management On 2/21/22 at 3:00 PM witnessed Staff B, Licensed Practical Nurse (LPN), applied 2 ice packs to Resident #140's right arm and hand due to pain. The Initial Care plan dated 2/6/23 for Resident #140 lacked mention of pain, pain management, and failed to contain a plan of care for pain. In an interview on 2/22/23 at 11:42 AM, the DON confirmed that the Care Plan did not address pain management, however the facility's practice is to locate orders with the Care Plan. When more information or clarification is needed, staff can refer to the orders. The DON stated, I would be chasing my tail if I had to write all those orders on the Care Plan when staff can just look at the orders, the Care Plan and orders are together on the chart. When asked about the plan of pain management versus looking at a list of orders, the DON stated, I can see where you're coming from, but staff can see that by looking at the orders. 47673 3. The MDS dated [DATE] for Resident #10 listed an admitted [DATE]. The MDS identified a BIMS score of 13, indicating no cognitive impairment. The MDS included diagnoses of unspecified fracture shaft of humerus, unspecified fracture upper end of humerus, and age related osteoporosis. Resident #10 had a scheduled pain medication regimen, PRN pain medication, and rated her pain at a 5/10, indicating moderate pain within the five days of the lookback period. The Care Plan Problem dated 1/20/23 indicated that Resident #10 had a humerus fracture that required her to need assistance with her activities of daily living (ADL's) while healing. The record review completed on 2/21/23 at 4:44 PM revealed for Resident #10's Comprehensive Care Plan lacked information related to pain.

Based on electronic record review, document review, and staff interview the facility failed to develop and implement policies and procedures, to ensure the resident's medical record included documentation that the resident did not receive COVID-19 immunizations due to refusal for 2 of 5 residents reviewed (Resident #141 and Resident #27). The facility reported a census of 36 residents. Findings included: 1. The Minimum Data Set (MDS) for Resident #27 documented she entered the facility on 5/26/21. The MDS also documented a Brief Interview of Mental Status (BIMS) of 03 indicating severe cognitive impairment. The electronic and paper record review conducted on 2/21/23 at 1:30 PM revealed Resident #27 did not have documentation of a declination of the COVID-19 immunization. 2. The Minimum Data Set (MDS) for Resident #141 documented she entered the facility on 6/27/22. The MDS also documented a Brief Interview of Mental Status (BIMS) of 13 indicating no cognitive impairment. In an interview on 2/21/23 at 11:26 AM, Staff F, stated on the day of admission residents are offered vaccines and their history of vaccines are discussed. STaff F stated notes about vaccines are in the nurses notes on the day of admission as well. The electronic and paper record review conducted on 2/21/23 at 1:12 PM revealed that Resident #141 did not have documentation of a declination of the COVID-19 immunization. In an interview on 2/21/23 at 11:15 AM, Staff H, stated no declination of immunization refusal was completed for Resident #27. Staff H stated Resident #27 refuses all immunizations. Staff H stated the facility expectation is that declination form is filled out or charted in medical records for any immunizations that are declined or refused by residents. Staff H stated Resident #141 probably doesn't have a declination form either. Staff H stated Resident 141 might have refusal of immunization charted from the admission.

Based on record review and staff interview, the facility failed to develop a care plan to address respiratory deficits, goals and interventions for 2 of 5 residents reviewed for comprehensive care plans ( Resident # 29 and Resident #35). The facility reported a census of 39 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #29, identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified the resident as requiring extensive assistance with the physical assistance of 1 staff with transfers, bed mobility, locomotion, dressing, toileting and personal hygiene. The MDS revealed the resident as unsteady and required the assistance of 1 to stabilize. The resident required a walker or wheelchair. The MDS identified the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required oxygen therapy. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated 09/16/21, lacked any documentation addressing the resident's chronic respiratory diseases or breathing deficits. On 10/06/21 at 3:30 PM, the DON reviewed the care plan and stated she expected the comprehensive care plan to address the resident's chronic respiratory diseases. The DON made a signed notation on the resident's care plan, dated 10/06/21, that the resident utilized continuous O2 (oxygen) therapy. 2. The MDS for Resident # 35, dated 09/16/21 assessed a BIMs score of 9, indicating moderately impaired cognition. The MDS identified the resident to require extensive assistance with the physical assist of 1 staff with transfers, bed mobility, locomotion, dressing, toileting and personal hygiene. The MDS identified the resident as unsteady and only able to [NAME] with the assistance of staff. The resident required a walker or wheelchair for mobility. The MDS identified the resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident utilized oxygen therapy for low oxygen levels. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated 10/05/21, lacked any documentation addressing the resident's chronic respiratory diseases or breathing deficits. On 10/06/21 at 3:10 PM, the DON reviewed the care plan and stated she expected the comprehensive care plan to address the resident's chronic respiratory diseases. On 10/06/21 at 03:20 PM, when asked to provide a policy the DON stated the facilty did not have an oxygen policy; adding that the facility did not have a lot of policies. The DON stated the facility follows professional standards. When asked where staff go to look for professional standards, the DON did not give an answer.

Based on observation and staff interview, the facility failed to prepare, and serve food in accordance with professional standards for food safety. The facility reported a census of 43 residents. Findings include: 1. During an observation on 2/17/20 at 9:30 a.m. initial tour of the kitchen revealed the low water temperature (temp) dishwasher ran with a wash temp of 115 degrees and rinse of 118 degrees. A review of the temp record showed multiple temps under 120. The facility had no record of the chemical checks. The Dietary Supervisor (DS) stated they did the checks daily, but did not record them. A check at the time revealed 50 parts per million (ppm) of chemical. She would check with their supplier regarding the dishwasher temps. The Dishwasher Temp record showed the temp recorded 3 times a day. The February 2020 record through 2/17/20 recorded rinse temps were below 120 degrees 29 of 51 times. A manual for Low Temp, Low Energy Dishwashers technical data included a minimum wash temp of 120 degrees. 2. During an observation on 2/18/20 at 10:41 a.m. Staff H (Cook) washed her hands, reached around the wall and obtained a paper towel, turned the faucet off then dried her hands with the same paper towel. During the meal service Staff H washed her hands in the manner stated above 6 times During an observation on 2/18/20 at 11:18 a.m. Staff I (dietary aide) washed her hands and turned the faucet off with her bare hand and then got a paper towel and dried her hands. During the meal service Staff I washed her hands in the manner described 3 times. During an interview on 2/18/20 at 12:25 p.m. the DS stated after washing hands, staff should dry their hands then turn the faucet off with a paper towel. A facility Food Safety Handwashing Techniques sheet including after washing hands, dry with a single use towel, then use towel to turn the faucet off.

Based on observation, clinical review and staff interview the facility failed to discard outdated medications for 3 of 43 residents (Resident #15, Resident #38, Resident #19), and failed to securely store drugs subject to abuse for 5 of 43 residents (Resident #13, Resident #193, Resident #37, Resident #34, Resident #42). The facility reported a census of 43 residents. Findings include: In an observation of one out of three medication carts on 2/17/20 at 12:37 PM Registered Nurse (RN) Staff L was administering the afternoon medications. Upon inspection of the medication cart it was revealed that a saline nasal spray for Resident #15 had been opened and dated 3/25/19, the expiration date was 10/2019. A review of the record showed that the resident was admitted to the facility on [DATE]. The clinical record showed a physician's orders [REDACTED]. Upon further inspection of the medication cart it was discovered that Resident #38 had five individual sample packs in with her medication cassettes. Each of the packets contained two soft-gel tablets. Staff J, RN stated that the resident received these samples from the optometrist. Upon further investigation it was discovered that the expiration date on the packets was December of 2019. A review of the clinical record revealed that Resident #38 admitted to the facility on [DATE]. The record showed a doctor's order dated 5/20/19 for Preservation [MEDICATION NAME] 2 soft gel- take one orally (PO) every (Q) day/eye vitamin, may use sample supply. The medication cart also contained a cassette of [MEDICATION NAME] 500 milligrams (mg) for Resident #19. The expiration date on the medication was January of 2020. A review of the Medication Administration Record [REDACTED]. The clinical record showed a doctor's order on 4/5/17 for: [MEDICATION NAME] 500 milligrams (mg.) tab one tab PO every 6 hours as needed (PRN) for pain. In an interview with registered nurse (RN) Staff J on 2/17/2020 at 12:57 PM she stated the nurse administering the medications should have discovered the outdated medications. In a second observation of the three medication carts on 2/19/20 at 11:55 AM it was discovered that antianxiety medications were kept under one lock. The scheduled and PRN (as needed) antianxiety medications were kept in cassettes with individual compartments for each dose. According to the Assistant Director of Nursing (ADON) in an interview 2/19/20 at 3:06, the routines is for the scheduled medications to be replaced every two weeks but the PRN cassettes were only renewed as needed. The facility had no process in place to keep a count of the PRN antianxiety drugs. A chart review revealed the physician's orders [REDACTED]. On 2/19/20 at 12:00 PM, Staff K, RN reviewed the electronic clinical record for doctor's orders, as the surveyor took out cassettes of PRN medications from the medication cart. The following was discovered: A cassette of [MEDICATION NAME] (antianxiety) 0.5 mg PRN for Resident #13 with 11 pills in the cassette. The last doctor's order for this medication was initiated on 12/9/19 and had expired on 12/23/19. A cassette of [MEDICATION NAME] 0.5 mg PRN twice a day (BID) for Resident #193. The doctor's order for this medication expired on 2/18/20 and the cassette contained remaining 15 tablets. A cassette of [MEDICATION NAME] 0.5 mg every 6 hours PRN for Resident #37. The doctor's order expired on 12/27/19 and 13 pills remained in the cassette. The PRN was used twice in December and not in November at all. A cassette of [MEDICATION NAME] 0.5 mg every day (QD) PRN for Resident #34. The doctor's order expired on 1/10/20 and 7 pills remained in the cassette. A review of the medication administration records (MAR) revealed the resident did not use the as needed medication in December, January or so far in February. In a review of the other two medication carts with Staff J, RN at 12:05 it was discovered that Resident #42 had a cassette of 0.5 mg [MEDICATION NAME] 1-2 tabs every 30 minutes. A review of the electronic chart revealed that the doctor's order expired on 2/18/20. There were 29 pills remaining in the two cassettes and the MAR indicated [REDACTED]. On 2/19/20 at 2:57 PM a report from the pharmacy was generated to help determine if any tablets were unaccounted for. The report was generated for three of the five residents with lapsed orders. Resident #37 had 16 tabs send to the facility on [DATE]. The MAR indicated [REDACTED]. Resident #34 had 14 tabs send to the facility on [DATE]. The MAR indicated [REDACTED]. Resident #13 had 16 tabs sent to the facility on [DATE]. Two of the pills were sent to the emergency kit on 11/21/19 and 14 put in a cassette to be kept in the medication cart. Over November and December three doses had been given to the resident and 11 tabs remained in the cassette. In an interview with the DON on 2/19/20 at 3:06 she said the cassettes with PRN medications should have been sent back to the pharmacy once the doctor's order expired. She stated that she understood the potential for abuse when antianxiety medication are not counted or used on a regular basis. On 2/20/20 at 8:30 AM the DON stated she placed the PRN benzodiazepine medications under a second lock and staff would count them on a regular basis in the future. She acknowledged that this may be a safer process.

Based on observation, record review and staff interviews, the facility failed to ensure that the resident environment remained as free from accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents reviewed. Resident #1 fell twice without alarms sounding. The second fall resulted in a right hip fracture that required surgical repair. It is unknown who shut the resident's room door prior to the fall. Resident #3's care plan identified he/she used an alarm. During the investigation, the surveyor observed the alarm box in the off position. It is unknown who shut it off. The facility reported a census of 56 residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 12/14/16, assessed Resident #1 with a brief interview for mental status (BIMS) score of 1 (severe cognitive impairment). The resident had the following indicators of delirium continuously present: inattention and disorganized thinking. The resident required extensive staff assistance with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. The resident required limited assistance of one staff with ambulation. A balance during transfers and ambulation test identified the resident with the score of 2 in all areas of testing other than turning around while walking which was not tested . A score of 2 identified the resident as unsteady and only able to stabilize with staff assistance. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. The resident had [DIAGNOSES REDACTED]. The resident did not have falls since the previous assessment. A care plan with problem onset date of 12/15/16, identified the resident with a self care deficit in ADL's (activities of daily living) related to requiring physical help with activities of daily living. Regarding alarms, the care plan identified the following interventions: seat alarm with hallway alert when in recliner, seat alarm when in dining room chair, motion alarm with hallway alert when in bed or recliner. Fall with bruises and skin tear: A resident incident report dated 12/17/16 at 4:16 p.m., revealed the resident tried to self ambulate to the bathroom and fell . Staff found the resident in the bathroom doorway laying on his/her right side. The resident sustained [REDACTED].) by 3 cm. and a skin tear and bruise to the left knee measuring 1 cm. by 2 cm. The immediate post incident action was to replace the battery in the motion alarm. The battery in the alarm was dead. A fall description detail sheet identified the alarm did not sound but the seat alarm did sound. Staff Interviews: On 1/31/17 at 12:40 p.m. Staff A CNA (certified nurse aide) stated she came up the hall to use the rest room and a resident notified her that Resident #1 needed help. Staff A did not hear an alarm and she was the first one to arrive to the room. On 1/31/17 at 4:19 p.m. Staff B CNA stated the resident appeared agitated the day of the fall. Another CNA (Staff A) came down the hall and found the resident. Staff B stated she didn't hear any alarms. She was in a room with another resident. She was the second one to the room and when she arrived, Staff A was with the resident and there was no alarm sounding then. She stated she heard Staff A call on the Walkie and at that time Staff A was the only one with the resident. When Staff B arrived, she didn't hear any alarms but she didn't know if Staff A may have shut them off. The DON (director of nursing) was not there yet. She stated she checked the resident's alarms at shift change ( 2 p.m.) and they functioned. They also went off several times prior to the fall. Staff did not document the checks. On 1/31/17 at 12:38 p.m. when asked about the alarms, the DON stated her report says the alarm sounded. She stated when she entered the room, she heard the alarm sounding. Fall with Fracture: A resident incident report dated 1/3/17 at 1:55 p.m., revealed the resident got up to open his/her door and fell . After the fall, the resident complained of right thigh/hip pain. A fall scene investigation report revealed the alarm was not in use when the fall occurred. The OTA (occupational therapy aide) did not activate the alarm after returning the resident to his/her room. A fall huddle also identified the alarm not in place at the time of the fall. Staff Interviews: On 1/31/17 at 10:33 a.m., Staff C RN (registered nurse) stated Staff D CNA came to her and said the resident's room door was shut. They went through the adjoining bathroom door and observed the resident on the floor. At that time, the resident stated he/she got up to shut the room door. Staff C stated she did not know how the door got shut. She stated she last observed the resident after lunch seated in a recliner in the resident's room resting quietly. Staff C stated she did not pay attention to how many alarm boxes the resident used. On 1/31/17 at 10:07 a.m. Staff D CNA stated she took the resident to the bathroom at 10:30 a.m. and the resident voided. The resident sat in his/her recliner and Staff D activated the alarms. Staff D stated the resident had one alarm box fastened to the wall outside the the room that contained the alarm for the motion and seat alarm that the resident used in the room. Staff D stated the resident also had a blue box alarm that went with the resident in the wheelchair. Staff D stated the next time she saw the resident, he/she was in the dining room having lunch. Staff D did not notice anything unusual. As lunch cleared, Staff E CNA said the OTA would take the resident back to his/her room. The next time Staff D saw the resident after that was when they found the resident on the floor in front of his/her sink. She went to check the resident because the room door was shut and that was unusual. Staff D did not know how the room door got closed. The resident's leg hurt so the ambulance came. Staff D stated no alarms sounded when the fall occurred. Staff D stated therapy is usually pretty good about resetting the alarms. On 1/31/17 at 9:25 a.m. Staff E CNA stated she observed the resident in the recliner around 1 p.m. with his/her feet up. The resident sat quietly. Staff E left the room door open. She stated she didn't notice if the motion and chair alarm were on. She stated Staff F OTA took the resident from the dining room table because she wanted to walk the resident. Staff E told Staff F that she did not need to take the alarm out of the wheelchair and put it in the recliner because the recliner already had an alarm. On the same date at 11:15 a.m. Staff E stated she didn't know anything about the resident no longer using a seat alarm on the day of the incident but stated she only worked part time. On 1/31/17 at 4:09 p.m. Staff G CNA stated she took the seat alarm out of the recliner on 12/16/16. Initially staff removed the floor alarm on that date. The floor alarm and seat alarm were synched to the same hall box so when she took the floor alarm away the seat alarm in the recliner did not work. They took the hall box leaving one hall box instead of 2. She stated she asked the DON about taking the seat alarm out of the recliner and just switching the blue wheelchair alarm box between wheelchair and recliner. The DON said yes so Staff G took the seat alarm away. Staff G stated the only alarm in place then was the motion alarm and then the blue wheelchair box alarm that staff transferred from wheelchair to recliner. She stated that is what the resident used from then (12/16/16) up to the time of the fracture On 1/31/17 at 11:30 a.m. the surveyor asked the DON about Staff G saying the facility discontinued the seat alarm prior to the two falls. The DON stated if changes like that are made they usually change the care plan and the care plan said the resident still used the seat alarm. On 1/31/17 at 9:38 a.m. Staff F OTA stated she placed the resident in the recliner after lunch and an hour later, the resident fell . She stated she could not recall if she placed or activated the alarm but she didn't know why she wouldn't have. She stated prior to leaving the dining room, she asked a staff about putting the wheelchair alarm in the recliner and they told her no the resident used a seat alarm in the recliner so she didn't need to. She stated there was only one alarm box in the hall (confirming what Staff G said) When asked how she knew what alarms residents used, Staff F stated there was nothing to go by. She just asked staff or else it was just by knowing. When asked what just by knowing meant, she stated it was by working at the facility long enough to know if there is a box outside the room door in the hall then staff needed to activate an alarm. Staff F stated the facility has books now and care plans available. On 1/31/17 at 9:56 a.m. the DON stated the alarm books and care plans have always been available at each nurses station. The DON stated it was the head of the therapy department's responsibility to educate their staff. She stated she was sure Staff F knew but evidently she didn't because she didn't do it. On 1/31/17 at 2:38 p.m. the head of therapy stated the therapy aides are educated verbally about alarms. There was no formal training. She stated therapy notes contained information about alarms and staff is also instructed to speak with nursing if they have a question. On 1/31/17 at 1:07 p.m. the surveyor double checked with Staff F if she knew about the alarm books and care plans. At that time,. Staff F stated she must have forgotten. She stated the information was also located on therapy notes on the computer and Ipad. On 1/31/17 at 11:30 a.m. the administrative support person stated she saw the resident resting in the recliner around 1:45 p.m. She observed the resident's room door open. The Administrative support person thought the resident had one alarm box outside the room in the hall at the tome of the observation. On 1/31/17 at 1:50 p.m. the social worker stated around 1:45 p.m. she saw the resident's room door open. Departmental notes dated 1/3/17 at 2:29 p.m. revealed a nurse aide called Staff C to the resident's room at 1:55 p.m. Staff found the resident on the floor laying on the left side. The alarm did not sound and OT was the last staff in the room with the resident. The resident complained of right thigh pain. The facility notified the physician and the resident transported to the emergency room (ER) for evaluation at 2:25 p.m. of the same date. Hospital discharge instructions dated 1/13/17 revealed the resident admitted to the hospital 1/3/17 after a fall that resulted in a right hip fracture. On 1/4/17 the resident underwent [REDACTED]. While in the hospital the resident received blood transfusions. The resident returned to the facility with orders for skilled care for physical/occupational therapy for strengthening and gait training. The resident was partial weight bearing when he/she returned to the facility. A major injury determination form dated 1/3/17 revealed the right fractured hip as a major injury. Observation showed on 1/31/17 at 11:45 a.m. 2 staff transfer the resident from bed to the wheelchair. The resident had a motion alarm by the bed and blue box alarm for the wheelchair. 2. A MDS with assessment reference date of 1/3/17 assessed Resident # 3 with a BIMS score of 9(moderate cognitive impairment). The resident admitted to the facility 12/27/16. The resident required extensive staff assistance with transfers and ambulation. A balance during transfers and ambulation test identified the resident with the score of 2 in all areas of testing other than turning a round while walking which was not tested . A score of 2 identified the resident as unsteady and only able to stabilize with staff assistance. The resident had [DIAGNOSES REDACTED]. A care plan with problem onset date of 1/6/17 identified the resident with a history of falls. The care plan directed the resident should utilize a motion alarm when in bed or recliner. Observation showed on 1/31/17 at 10:50 a.m. in his/her recliner in room. Observation revealed a motion alarm at the foot of the recliner. However the alarm box was not blinking, indicating the alarm was not on. The surveyor summoned Staff H LPN (licensed practical nurse) to have her look at the alarm box. Staff H confirmed the alarm box was not on and should be on. Staff H flipped a switch on the side so the alarm box was on. Staff H stated the last person she saw in the room was Staff I RN about 20 minutes ago. At 11 a.m. Staff I stated she went in the room but stated she hit the silence button and then reset the motion alarm and it beeped. She stated she did not touch the on/off switch. On 1/31/17 at 4:45 p.m. the DON stated she was unable to determine who turned the alarm box off. Observation showed on 1/31/17 at 1:15 p.m. the resident in a recliner in his/her room with motion alarm in place. At that time, the resident put his/her feet down and the alarm sounded. The surveyor was unable to determine who shut the alarm box off.