Every finding on record at Marian Manor Of Taunton

Based on observations, interviews, and records reviewed for one Resident (#5), of 17 sampled residents, the facility failed to ensure care was provided in accordance with professional standards of practice. Specifically, the facility failed, for Resident #5, to follow the prescriber's orders for how liquids were provided to the Resident. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:-Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error.Resident #5 was admitted to the facility in July 2022 with diagnoses including but not limited to dysphagia (difficulty in swallowing) and cerebellar ataxia (dysfunction or damage to the cerebellum, leading to impaired coordination, balance, and voluntary muscle control). Review of Resident #5's medical record indicated he/she was hospitalized in December 2025 with a diagnosis of aspiration pneumonia (a lung infection that develops after inhaling foreign material such as food, liquid, saliva, or stomach acid).Review of the December 2025 hospital discharge recommendations, from the Speech and Language Pathologist (SLP), indicated but was not limited to:-no mixed textures, no straws, aspiration precautions, all liquids by teaspoon.Review of Resident #5's Minimum Data Set (MDS) Assessment, dated 3/17/26, indicated the Resident has moderate cognitive impairment based on the Staff Interview Assessment. The MDS also indicated Resident #5 is dependent on staff for all care including eating.Review of the Resident's Physician's Orders, dated 4/15/26, indicated but were not limited to the following: honey thick, pureed, liquids via teaspoon, supervised and feed, head of bed elevated at 90 degrees, no straws. On 5/5/26 at 9:19 A.M., the surveyor observed Resident #5 with a thickened red beverage in a two handled cup with a straw in the cup on his/her overbed tray table.On 5/5/26 at 12:19 P.M., the surveyor observed Resident #5 with a thickened red beverage in a two handled cup with a straw in the cup on his/her overbed tray table.On 5/5/26 at 2:19 P.M., the surveyor observed Resident #5 with a thickened red beverage in a two handled cup with a straw in the cup on his/her overbed tray table.During an interview on 5/6/26 at 8:50 A.M., Certified Nursing Assistant (CNA) #3 said the Resident drank about 75 percent of his/her beverages and utilized the cup with the straw. She said she pours the thickened juice in the two handled cup with the lid and straw and leaves it on his/her bedside table if he/she doesn't finish it all at breakfast. She said she was unaware of any special instructions for providing the Resident with beverages/liquids.During an interview on 5/6/26 at 12:18 P.M., CNA #6 said she fed Resident #5 lunch and provided assistance with the strawed beverage. She said the Resident's food is puree and their liquids are thickened. She said she poured the juice in the two handled cup and assisted the Resident with the straw and held the cup for him/her. During an interview on 5/6/26 at 10:48 A.M., the Registered Dietitian said the diet order was a recommendation from speech therapy and it was the physicians' orders. She said she only addressed preferences and nutritional goals. She said the physician's order to be fed liquid with a teaspoon, no hot beverages, and no straws came from a speech therapist. During an interview on 5/7/26 at 9:11 A.M., Rehab Staff #1 said she discharged Resident #5 from Speech and Language services April 2025. She said any recommendations made at the hospital by their speech therapist would be considered the most recent orders. She said the orders from the hospital speech therapist override her recommendations since they were made most recently by a licensed SLP. She said the facility staff should be following the recommendations made by the SLP which then became physician's orders. She said there was no way to measure a teaspoon sip with a straw. She said the Resident should not be using a straw since the physician's order indicates no straws. During an interview on 5/7/26 at 1:00 P.M., the Director of Nurses (DON) said it was her expectation that the physician's orders are being followed by all staff members. She said the physician's orders are to ensure Resident safety and comfort and should be followed to ensure the Resident is receiving liquids by teaspoon to ensure the correct amount is swallowed at the right speed. She said the order is accurate and correct and does not know why it hasn't been being followed.

Based on observation, interview and record review, the facility failed to maintain a safe environment free of potential accident hazards for one Resident (#30), out of a total sample of 17 residents. Specifically, for Resident #30, the facility failed to implement interventions to prevent falls by ensuring his/her bed was in the lowest possible position and he/she had access to their call bell.Findings include:Review of the facility's policy titled Fall Prevention Program, dated 10/25, indicated but was not limited to the following:Purpose: To prevent resident falls through the systematic and regular identification of risk factors for each resident.-Interdisciplinary care plans will be established, revised, and reviewed each time a resident falls. Appropriate interventions to maintain a resident's safety will be included. Resident #30 was admitted to the facility in December 2025 with diagnoses including but not limited to: Huntington's disease (disease which causes nerve cells in the brain to decay over time. The disease affects a person's movements, thinking ability and mental health) and repeated falls.Review of Resident #30s Minimum Data Set (MDS) Assessment, dated 3/3/26, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, which indicated Resident #30 had no severe cognitive impairment. The MDS also indicated Resident #30 was dependent on staff for all functional tasks. Section J of the MDS indicated the Resident has had two or more falls since admission. Review of Resident #30's Physician's Orders, dated 12/6/25, indicated:-bed in low position at all times while resident is in bed. Review of Resident #30's care plan indicated the following: Problem: High risk for falls due to impaired memory, impaired mobility, poor safety awareness and spastic movements due to my Huntington's disease. I do not remember to use the call light for assistance, dated 3/10/26.Goal: I do not want to fall and get hurt, dated 3/10/26.Approach: Before you leave me, make sure my call light is in reach, dated 12/9/25.Check on me frequently for safety and for the need to use the bathroom, dated 12/9/25.I have a low bed, please make sure it is in the lowest position before you leave, dated 12/9/25.On 5/6/26 at 7:05 A.M., the surveyor observed Resident #30 in his/her room alone with the door closed almost all the way. The Resident's lower body was on a thick fall mat (size of mattress) next to his/her bed, and his/her neck was at an angle still on the side of the bed. Resident #30 was observed yelling, Help me! Help, someone! The surveyor observed the bed not to be in the lowest position possible, and the call bell was against the wall at the head of bed on the floor.On 5/6/26 at 7:20 A.M., the surveyor observed four staff members enter Resident #30's room to assist him/her back to bed. The four staff members exited the room; the surveyor entered Resident #30's room and observed the Resident in his/her bed. The bed was not in the lowest possible position, and the call bell was against the wall at the head of the bed on the floor not within reach of the Resident.On 5/6/26, from 7:35 A.M. until 10:15 A.M., the surveyor observed Resident #30 unsupervised in his/her bed which was not in the lowest possible position when maintenance changed out the bed for a functioning bed. During this time the call light remained on the floor next to the head of bed on the floor.During an interview on 5/7/26 at 7:40 A.M., Nurse #3 said he saw Resident #30 on the floor at 7:00 A.M. and he left the Resident and closed the door to go get help. He said he needed three other staff members to safely get the Resident back into bed. He said he and three other staff members transferred the Resident back into bed and that is when he was aware the bed was broken and would not mechanically rise or lower. He said he was not sure how long the bed was broken or how long the Resident was in bed which was not in the lowest possible position. He said he did put the Resident back in the broken bed and is waiting to hear from Maintenance about what to do. He said he should not have left the Resident alone or put the Resident back into the broken bed unsupervised.During an interview on 5/6/26 at 9:06 A.M., Nurse #2 said she was the 11-7 supervisor working last night for both units. She said it was everyone's responsibility to ensure Resident #30's bed was in the lowest possible position to avoid injury since he/she has a history of falls. She said she should have been alerted to any issues including maintenance but was unaware of any issues with Resident #30's bed. She said the Resident's care plan and orders reflect his/her bed should always be in the lowest position. and his/her call bell should be within reach. During an interview with an observation on 5/7/26 at 10:00 A.M., the Director of Nurses (DON) said the bed should have been checked to ensure it was in the lowest position multiple times and since no one ensured it was, the Resident fell at a height that puts the Resident at higher risk for injury. She said all staff are responsible for rounding and ensuring the Resident is kept safe from accidents and injury. She said the Resident should not have been put back into the known broken bed and left unsupervised. She said the staff should have ensured the call light was within reach and not on the floor out of reach.Refer to F908

Based on observation and interview, the facility failed to ensure one Resident (30), out of a total sample of 17 residents, had a bed that was in safe operating condition. Specifically, Resident #30's bed was unable to be positioned in the lowest possible position. Findings include:Review of the facility's policy titled Policy and Procedure for Bed Assessment Regulatory Compliance, dated 3/26, indicated but was not limited to the following: -Using the Bed Assessment tool and documentation form the maintenance department will perform and document a bed assessment every time bed rails or new mattresses are installed. -Vendor supplied beds need to be in compliance with the bed assessment requirements prior to resident use. The maintenance department will perform/document a bed assessment on a vendor supplied bed preferably with the vendor if changes to the bed/mattress/rails are required to be in compliance with the Bed Assessment Regulations. After the vendor supplied bed passes the bed assessment, it can be placed in service for resident use. Resident #30 was admitted to the facility in December 2025 with diagnoses including but not limited to: Huntington's disease (a brain disorder that causes the nerve cells to break down and die which can affect a person's movement, thinking ability and mental health) and repeated falls.Review of Resident #30's Minimum Data Set (MDS) Assessment, dated 3/3/26, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, which indicated Resident #30 had severe cognitive impairment. The MDS also indicated Resident #30 was dependent on staff for all functional tasks. Review of Physician's Orders, dated 12/6/25, indicated: bed in low position at all times while resident is in bed. On 5/6/26 at 7:05 A.M., the surveyor observed Resident #30 in his/her room alone with the door closed almost all the way. The Resident's lower body was on a thick fall mat (size of mattress) and his/her neck was at an angle still on the side of the bed. Resident #30 was observed yelling, Help me! Help, someone! The surveyor did not observe the bed in the lowest position possible. During an interview on 5/7/26 at 7:40 A.M., Nurse #3 said the bed Resident #30 was in was not working and would not go down to the lowest position possible. He said the Resident fell from a distance that should have been preventable if the bed was working. He said the Resident was back in bed at this time and he has a call down to maintenance to see if they can repair the bed. The nurse confirmed the Resident was put back in the broken bed after his/her fall and confirmed the bed was still not functioning properly. He said the bed the Resident was in was delivered last week. During an interview on 5/6/26 at 7:50 A.M., the Maintenance Director said the bed was a rental and he was not sure if he was able to repair it. He said this was not a facility supplied bed, so it was likely he would not have the required parts. He said he was going to call the company which delivered it. He said there was no process for inspecting or assessing equipment delivered by vendors into the building and this bed was not inspected prior to Resident #30's use. He said there should be a process to ensure there was an understanding of what to do if it malfunctions, and how to reach the vendor, and ensure the equipment was working at time of delivery. He said the bed was delivered on 4/30/26 and the only time he would review the bed would be during monthly entrapment inspections, which had not occurred since the bed was delivered.During an interview on 5/6/26 at 9:06 A.M., Nurse #2 said she was the 11-7 supervisor working last night for both units. She said it was everyone's responsibility to ensure Resident #30's bed was in the lowest possible position to avoid injury since he/she has a history of falls and rolling out of bed. She said she should have been alerted with any issues including maintenance but was unaware of any issues with Resident #30's bed. She said the bed was delivered by the vendor last week and she doesn't believe any inspections were completed to ensure safety and functioning of the bed.During an interview on 5/7/26 at 10:00 A.M., the Director of Nurses (DON) said it was the facility's responsibility to ensure that all equipment coming into the facility was in good working order.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP), the Facility failed to ensure nursing promptly notified his/her Health Care Agent (HCA), when nursing transcribed a physician's order to decrease the dosage of his/her antidepressant medication without notifying the HCA of the change, Resident #1 received the lower dosage of the medication for more than a month before the HCA was made aware.Findings include:Review of the Facility's Policy titled, Change in Resident Condition, dated as revised December 2025, indicated the following:-the resident's responsible party/next of kin are notified of a change in condition;-a licensed nurse in charge is responsible for timely notification of the responsible party/next of kin and notify with his or her consent the resident representative when there is: a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment;-all changes and notifications should be documented in the resident's medical record.Resident #1 was admitted to the Facility in March 2020, diagnoses included: non-displaced intertrochanteric fracture of left femur, Alzheimer's disease, osteoarthritis, occlusion and stenosis of carotid artery, anxiety disorder, Bullous disorder, cellulitis of right and left lower limb, chronic obstructive pulmonary disease and recurrent major depressive disorder.Review of Resident #1's Medical Record indicated Resident #1's Health Care Proxy was invoked on April 15, 2020.Review of Resident #1's Advanced Directives Care Plan, dated as initiated 03/18/2022, reviewed and revised with the Annual Minimum Data Set (MDS) Assessment, dated 11/12/25, indicated that Resident #1 had an invoked HCP and that his/her family will be contacted as necessary in order to be kept up to date with any changes in his/her condition.Review of a Consultant Pharmacist Recommendation to Prescriber Form, dated 09/30/25, indicated that Resident #1 currently receives Sertraline 100 mg by mouth daily, dose evaluation is recommended periodically in order to help determine the lowest effective dose and to attempt to taper Sertraline unless clinically contraindicated. The Form indicated that the NP agreed with the recommendation, wrote a new order for Sertraline and wrote that it was unlikely that the HCA would agree with the GDR.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted on 12/23/25, indicated that on 09/30/25 the facility's pharmacy consultant recommended that Resident #1's Sertraline (antidepressant medication) be decreased from 100 milligrams (mg) by mouth daily to 75 mg by mouth daily. The Report indicated that the Nurse Practitioner (NP) agreed with the gradual dose reduction (GDR) and on 10/03/25 wrote an order to decrease the Sertraline from 100 mg to 75 mg by mouth daily. The Report indicated that the NP wrote on the pharmacy recommendation form that Resident #1's HCA probably would not agree with the recommendation. The Report indicated that on 10/03/25 the Nursing Supervisor transcribed the NP's order to decrease Sertraline to 75 mg in Resident #1's Electronic Medical Record (EMR) and was under the impression that a conversation took place with Resident #1's HCA prior to the order being written.The Report indicated that on 11/20/25 Resident #1's HCA attended a Quarterly Care Plan Meeting, and his/her plan of care was reviewed which included his/her current medications. The Report indicated that Resident #1's HCA stated that he/she was not notified of the decreased dosage of Sertraline prior to the meeting and requested that the Sertraline be increased back to 100 mg. The Report indicated that the NP was notified of Resident #1's HCA's request and on 11/21/25 Sertraline was increased to 100 mg by mouth daily. During a telephone interview on 01/15/26 at 2:10 P.M., Resident #1's HCA said that Resident #1 receives an antidepressant medication and that he/she had requested that the dosage of the medication not be changed. The HCA said that in November 2025 at a care plan meeting, she was informed that the dosage of Resident #1's antidepressant medication was decreased in October 2025. The HCA said that as Resident #1's HCA, that the facility was supposed to notify her of any medication changes and said that the facility just decreased the dose of Resident #1's antidepressant without notifying her prior to implementing the lower dose. Review of a Physician's Order, dated 10/03/25, indicated to discontinue Sertraline 100 mg by mouth daily and administer Sertraline 75 mg by mouth daily.Review of Resident #1's Medication Administration Record, dated 10/04/25 through 11/21/25 indicated that Resident #1 received Sertraline 75 mg by mouth daily.During an interview on 01/15/26 at 12:45 P.M., the Nurse Practitioner (NP) said that she reviewed Resident #1's Pharmacist GDR recommendation to decrease Sertraline, agreed with the recommendation and wrote an order to decrease Sertraline to 75 mg daily. The NP said that she agreed with the dose reduction pending Resident #1's HCA's approval. The NP said that it was her expectation that nursing would notify Resident #1's HCA of the recommendation to lower the dose of Sertraline and obtain approval before implementing the new order. During a telephone interview on 01/21/26 at 8:20 A.M., Nurse Supervisor #2 said that she transcribed the NP's order for Sertraline 75 mg into Resident #1's EMR. Nurse Supervisor #2 said that she thought that the NP had discussed the dose reduction with Resident #1's HCA prior to writing the order for Sertraline and assumed that the HCA approved the lower dosage of Sertraline. Nurse Supervisor #2 said she was not aware that Resident #1's HCA was not notified of the dose reduction of Sertraline.Review of Resident #1's Medical Record indicated that there was no documentation to support that Resident #1's HCA was notified of the dose reduction of Sertraline.During an interview on 01/15/26 at 4:00 P.M., the Director of Nurses (DON) said that the NP wrote an order to decrease Resident #1's Sertraline per the Pharmacist's GDR recommendation. The DON said that Resident #1 had an invoked HCP and the Nursing Supervisor transcribed the order without notifying Resident #1's HCA of the new dosage recommendation. The DON said that it was her expectation that nursing notified the HCA of any changes in medication dosage prior to implementation.

Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the facility failed to ensure his/her environment was free of accident hazards as possible, when on 06/28/25, while activity staff were assisting residents onto the elevator after an activity, they did not lock the elevator, which would have kept the door in the open position, as Resident #1 entered the elevator the door began to close and hit him/her causing him/her to fall into the elevator. Resident #1 complained of severe left leg pain and was transported to the Hospital Emergency Department (ED) for evaluation. Resident #1 was diagnosed with a left intertrochanteric fracture (break in the upper part of the thigh bone (femur), was admitted and underwent surgical intervention to repair the fracture.Findings include:Review of the Facility Policy titled, Fall Prevention Program, dated October 2024, indicated the following:-each resident will be assessed for risk factors and predisposition for falling using the Facility Fall Risk Assessment Form;-residents who experience a fall will have a Fall Risk Assessment completed by the Nurse Manager/Supervisor or designee on duty at the time of the fall which includes a detailed nurse's note, an incident report and incident investigation follow-up;-the Nurse Manager/designee will review the fall prevention/incident interventions/staff educations with all staff;-physician and family members will be notified by the nurse on duty at the time a resident falls.Review of the Facility Policy tilted, Accidents and Incidents Investigation, undated, indicated the following:-begin an investigation: what happened to the resident, who was involved with the resident, how did this happen and how can we prevent this from happening again;-interview the resident, the caregivers, the recreation staff;-observe the environment where the resident was found;-assist the resident and staff with completion of statements;-review all statements and ensure all questions have been addressed;-director of nurses (DNS) reviews accidents and incidents;-DNS reviews if staff performed duties according to standard of practice;-DNS ensures there is a plan so that the problem will not continue to occur.Review of the Facility Policy titled, Formal Investigation Guidelines, dated March 2025, indicated the following:-incidents have many causes including unsafe conditions, unsafe acts such as not following procedures;Resident #1 was admitted to the Facility in October 2015, diagnoses included bipolar disorder, hypertension, major depressive disorder, anxiety, chronic kidney disease, hypothyroidism and cataracts.Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 04/15/25, indicated that he/she was alert, oriented and independent with ambulation.Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 06/28/25, indicated that at 11:00 A.M, Resident #1 was ambulating into the first-floor elevator after activities, lost his/her balance and fell onto his/her left side in the doorway of the elevator. The Report indicated that the fall was witnessed by an activities staff member. The Report indicated that Resident #1 complained of left hip and leg pain, the Nurse Practitioner and Health Care Agent were notified, and he/she was transferred to the Hospital Emergency Department (ED) for evaluation. The Report indicated that Resident #1 was admitted to the hospital, was diagnosed with a left intertrochanteric fracture and had an Open Reduction Internal Fixation (ORIF, surgical procedure to repair broken bones with hardware) of his/her left hip.Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 presented to the ED after a fall at the nursing home. The Summary indicated that Resident #1 had a left intertrochanteric femur fracture resulting from the fall and underwent an ORIF surgical procedure. The Summary indicated that Resident #1 also had mild anemia secondary to the hip fracture and subsequent surgery.During a telephone interview on 08/19/24 at 11:25 A.M., Family Member #1 said that Resident #1 told him/her on 6/28/25 that while he/she was walking into the elevator, the elevator door closed and hit him/her, causing him/her to fall into the elevator. Family Member #1 said that no one from Facility Administration told him/her that the elevator door closing and hitting Resident #1 was the reason why Resident #1 fell. Review of Activity Assistant #1's Written Witness Statement, dated 06/28/25, indicated that at approximately 11:10 A.M., Resident #1 was walking into the elevator when he/she lost his/her balance and fell to the floor.During an interview on 08/19/25 at 12:00 P.M., Activity Assistant #1 said that on 6/28/25, as Resident #1 walked into the elevator, the elevator door started to close, hit Resident #1 on his/her right arm, he/she lost his/her balance and fell to the floor of the elevator onto his/her left side. Activity Assistant #1 said she was behind Resident #1 transporting another Resident into the elevator when Resident #1 walked into the elevator. Activity Assistant #1 said that she should have locked the elevator (door stays in the open position) while she was transporting residents into the elevator so the elevator door would not close. Activity Assistant #1 said, on the day of the incident, she did not lock the elevator so that the elevator door would not close. Review of the Nursing Supervisor's Written Witness Statement, dated 6/28/25, indicated that at approximately 11:10 A.M., she was called to the elevator on the first floor to assess a resident who had fallen in the elevator. The Statement indicated that upon assessment, Resident #1 was sitting upright in the doorway of the elevator leaning up against the left side of the elevator with his/her whole body aligned to the left side. The Statement indicated that Resident #1 complained of severe pain and grabbed onto his/her left lower extremity and upon assessment, his/her left lower extremity was slightly internally rotated. The Statement indicated that his/her Health Care Agent (HCA), the Nurse Practitioner (NP) and Emergency Medical Services (EMS) were notified, and Resident #1 was transferred to the ED for evaluation of his/her injuries.During an interview on 8/19/25 at 2:15 P.M., the Nursing Supervisor said that she was called to the first floor front elevator area because Resident #1 had fallen. The Nursing Supervisor said that upon arrival, Resident #1 was leaning on the left side of the elevator doorway/floor on his/her left side. The Nursing Supervisor said that Resident #1 complained of left hip pain and wanted to call his/her daughter. The Nursing Supervisor said that Resident #1 spoke to his/her daughter on the telephone in Spanish. The Nursing Supervisor said that she then spoke to Resident #1's daughter (who translated what Resident #1 had said) on the telephone and said that Resident #1's daughter told her that Resident #1 said that no one held the elevator door open, the elevator door closed and hit him/her causing him/her to fall while he/she was walking into the elevator.The Nursing Supervisor said that Activity Assistant #1 told her that Resident #1 was walking into the front elevator when the elevator door closed, hit him/her and caused him/her to fall onto the elevator floor. The Nursing Supervisor said that she notified the Director of Nurses of what Activity Assistant #1 and Resident #1's daughter told her had happened. The Nursing Supervisor said that the front elevator door was not in the locked position when the fall occurred and said that the elevator should always be in the locked position so that the elevator remains open while residents are being transported into or out of the elevator. During a telephone interview on 08/21/25, the Director of Therapeutic Activities said that she was on vacation when Resident #1 fell. The Director of Therapeutic Activities said that when she returned to work, the Administrator and Activity Assistant #1 told her that when Resident #1 walked into the front elevator, the elevator door hit him/her and caused him/her to fall into the elevator. The Director of Therapeutic Activities said that the elevator should be locked if there is a lengthy time that it needs to remain open to transport residents in and out of the elevator. The Director of Therapeutic Activities said that she was not aware of any written facility policy or procedure regarding locking the elevator during resident transport, but that staff knew they needed to lock the elevator.Review of an Elevator Invoice and Repair Document, dated 6/04/25, indicated that the front elevator was not level with basement floor and was shutdown. The Document indicated that the doors were found out of adjustment, doors were realigned and readjusted entire operation including clutch retraction, elevator was tested extensively and returned to service.Review of an Elevator Invoice and Repair Document, dated 6/24/25, indicated furnish and install new contactor. The Document indicated retro-fit new accelerating contactor in place of old unit, lengthened wires and rewired, elevator was tested extensively and returned to service.During an in-person interview on 08/19/25 at 2:00 P.M. and a subsequent telephone interview on 8/26/25 at 9:48 A.M., the Director of Facility Operations said that he was never informed by Administration or anyone that a fall had occurred in the front elevator. The Director of Facility Operations said he was unaware of any resident incidents involving the front elevator. The Director of Facility Operations said that the front elevator was repaired a few times in June 2025, once because the elevator was not level with the floor when it stopped and the second was due to the elevator door not closing and remaining in the open position.The Director of Facility Operations also said a relay was installed so that the elevator door would open if it sensed something was in the way. The Director of Facility Operations said that the elevator should be locked when residents are being transported on and off the elevator so that the elevator remains open and the elevator door does not close.During an interview on 08/19/25 at 3:20 P.M., the Director of Nursing (DON) said that she received a call from the Nursing Supervisor that Resident #1 had lost his/her balance while walking into the front elevator and fell. The DON said that she asked the Nursing Supervisor if there was anything wrong with the front elevator and said she was told by the Nursing Supervisor that there was nothing wrong with the front elevator. The DON said that she notified the Director of Facility Operations of the fall involving the front elevator.The DON said that Resident #1's Family Member told her that Resident #1 told him/her that the elevator door struck him/her and caused him/her to fall. The DON said that she was not informed by any staff member that the elevator door hit Resident #1 and caused him/her to fall and said that it was inconclusive if the elevator door hit Resident #1. The DON said she did not know if the elevator was locked at the time of the incident. The DON said that it was her expectation that the elevator be locked so that the elevator remains open and the elevator door does not close when residents are being transported on and off the elevator.During an interview on 08/19/25 at 3:55 P.M., the Administrator said that she was informed that Resident #1 fell in the front elevator and witness statements were obtained. The Administrator said that she was informed that Resident #1 walked into the elevator, lost his/her balance and fell in the elevator. The Administrator said that she did not know how Resident #1 fell, that she was not present during the fall. The Administrator said that it was her expectation that the elevator be locked so that the elevator remains open and the elevator door does not close when residents are being transported on and off the elevator. The Administrator said she did not know if the elevator door was locked during the 6/28/25 incident.

Based on record review and interview, the facility failed to ensure staff notified the Physician of medication recommendations for one Resident (#15), out of a sample of 15 residents. Specifically, the facility failed to notify the Physician and/or Nurse Practitioner, in a timely manner, of the Psychiatric Nurse Practitioner (PNP)'s recommendations to increase Remeron (an antidepressant medication) dosage and implement a Gradual Dose Reduction (GDR) for Lexapro (an anti-anxiety medication), resulting in a 43-day delay in implementing the recommendations. Findings include: Resident #15 was admitted to the facility in June 2019 with diagnoses that included Alzheimer's disease, dementia, anxiety disorder, and major depressive disorder. Review of Resident #15's Psychiatric Nurse Practitioner (PNP) progress note/consult, dated 11/25/24, indicated but was not limited to the following: -Recommend GDR Lexapro (escitalopram). -Increase Remeron (mirtazapine) to decrease depression/enhance appetite. Review of Nurse Practitioner (NP) Encounter Notes, dated 12/11/24, 12/20/24, and 12/31/24, indicated but was not limited to: -Reviewed medications; escitalopram 10 mg (filled 6/29/22), escitalopram 5 mg (filled 9/1/24), mirtazapine 15 mg (filled 9/1/24). The NP's Encounter notes failed to address the PNP's recommendations to increase Remeron and implement a GDR of Lexapro made on 11/25/24. Review of a Physician's Encounter note, dated 12/18/24, indicated but was not limited to: -Reviewed medications; escitalopram 10mg (filled 6/29/22), escitalopram 5mg (filled 9/1/24), mirtazapine 15mg (filled 9/1/24). The Physician's Encounter note failed to address the PNP's recommendations to increase Remeron and implement a GDR of Lexapro made on 11/25/24. Review of the NP's Encounter note, dated 1/10/25, indicated but was not limited to: -Reviewed medications; escitalopram 10mg (filled 6/29/22), escitalopram 5mg (filled 9/1/24), mirtazapine 15mg (filled 9/1/24). -Assessment/Plan: Major depressive disorder, 1/7/25- Seen by Psych services and recommending GDR of Lexapro to 10mg and increase in Mirtazapine to 22.5mg. Order written and patient to be monitored for behavioral changes. Further review of the medical record failed to indicate that there were additional PNP notes after 11/25/24. Review of Resident #15's November 2024 through January 2025 Medication Administration Records (MARs) indicated he/she was administered the following medications as ordered: -Escitalopram oxalate, 5mg, 3 tabs once a day, (dated 9/6/23-1/7/25); -Escitalopram oxalate, 5mg, 2 tabs (=10mg) once a day, (dated 1/7/25 - open ended); -Mirtazapine, 15mg, at bedtime, dated (dated 6/15/23 - 1/7/25). -Mirtazapine, 15mg, administer three half tabs (22.5mg) at bedtime, dated (dated 1/8/25-1/10/25). -Mirtazapine, 45mg, administer 1 half tab (22.5mg) at bedtime, dated (dated 1/10/25-open ended). Review of Resident #15's current Physician's Orders indicated but were not limited to the following: -Escitalopram oxalate, 5mg, 2 tabs to equal 10mg, once a day, 1/7/25; -Mirtazapine, 45mg, 1 half tab (22.5mg), at bedtime, 1/10/25. During an interview on 3/10/25 at 9:33 A.M., Nurse #3 said the PNP sends recommendations electronically to the Director of Nursing (DON) or Unit Manager who then places recommendations into the Physician's and/or NP's folder for review. Nurse #3 reviewed Resident #15's 11/25/24 PNP's recommendations and medication orders and said there was a big gap in time between the recommendation and implementation of the orders for Remeron and Lexapro. Nurse #3 said the change in Unit Managers for that unit might have contributed to the lapse in communication. During an interview on 3/10/25 at 9:45 A.M., the DON said the PNP emails reports and recommendations to the DON, Administrator, and MDS nurse. The DON reviewed the PNP's 11/25/24 recommendations for Resident #15. The DON was unsure why there was a 43-day delay in implementing the PNP's recommendations for Remeron and Lexapro. During a telephonic interview on 3/10/25 at 11:55 A.M., the Physician said he expected the facility to notify him or the NP in a timely fashion of any consultant recommendations. During a telephonic interview on 3/10/25 at 12:13 P.M., the PNP said recommendations are emailed to the DON, Administrator, and supervisors, and the Assistant Administrator and Social Services also received the emails since there were no unit supervisors in place currently. The PNP said there are rarely any issues with sending these emails or the facility receiving them. The PNP said she could not recall specifically why her Remeron or Lexapro recommendations were implemented 43 days after the recommendations were made. During an interview on 3/10/25 at 3:00 P.M., the DON said she was able to locate the PNP's 11/25/24 recommendations in her email. The DON said the Unit Manager, who was no longer at the facility, was responsible for printing the recommendations from the email and placing them into the Physician's and NP's folders for review. The DON said she was unsure why there was such a delay in getting the recommendations to the Physician/NP. During a telephonic interview on 3/11/25 at 2:25 P.M., the NP said she receives consultant recommendations in her folder located on the units. The NP said she aims to address consultant recommendations in a timely manner and was unsure why she became aware of the PNP's 11/25/24 recommendations to increase Resident #15's Remeron and implement a GDR for his/her Lexapro in January. The NP said there was a new Unit Manager in place when the PNP made the recommendations which could have affected when the NP received the recommendations. The NP said she and the PNP have increased direct communication with each other to lessen notification delays.

Based on interview and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) Committee which included the required members at their meetings. Specifically, the facility Medical Director and Director of Nurses (DON) each failed to attend one of five Quarterly QAPI meetings reviewed. Findings include: Review of the facility's policy titled Quality Assurance on Performance Improvement (QAPI) Program, dated as revised 4/2024, indicated but was not limited to: -A facility must maintain a Quality Assessment and Assurance provision at 42 CFR, Part 483.75 (0) Quality Assessment and Assurance: 1. A facility must maintain a Quality Assessment and Assurance Committee consisting of: (i) the Director of Nursing Services; (ii) A physician designated by the facility; and (iii) At least 3 other members of facility's staff Review of the facility's QAPI Attendee sign-in sheets for January 2024 indicated the Medical Director was not in attendance. Review of the facility's QAPI Attendee sign-in sheets for July 2024 indicated the DON was not in attendance. During an interview on 3/10/25 at 1:59 P.M., the Administrator reviewed the January and July 2024 QAPI attendance sheets and said that the Medical Director was not present for the January 2024 QAPI meeting and must have been on vacation and the DON was not present for the July 2024 QAPI meeting and may have been on vacation at that time.

Based on observations, interviews, and records reviewed for two Residents (#19 and #48) of 15 sampled residents, the facility failed to ensure care was provided to residents in accordance with professional standards of practice. Specifically, the facility failed: 1. For Resident #19, to ensure a prescriber's order for Dycem (a thin, rubberlike material known for its non-slip material, used to reduce the likelihood of sliding or shifting) to wheelchair was implemented to prevent falls; and 2. For Resident #48, to follow the prescriber's orders for 1:1 (one to one) assistance and encouragement with meals. Findings include: Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following: -The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following: -Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescriber that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. 1. Resident #19 was admitted to the facility in April 2019 with diagnoses including chronic pain syndrome and diabetes mellitus. Review of the Minimum Data Set (MDS) assessment, dated 1/22/25, indicated Resident #19 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Further review of the MDS assessment indicated he/she had two or more falls without injury since the previous MDS assessment. Review of Resident #19's current Physician's Orders indicated but was not limited to: -Dycem to wheelchair at all times, check placement every shift, dated 11/19/24 Review of Resident #19's care plans indicated he/she was at high risk for falls due to impaired mobility and medication use. Further review of his/her care plans indicated interventions to prevent falls which included: -Please ensure I have dysem [sic] on my wheelchair (I remove the dysem [sic] from my chair when I want to), dated 11/21/24 Review of the Medication Administration Record (MAR) for 1/15/25 and 1/16/25 the order for Resident #19's Dycem was signed off every shift indicating the Dycem had been in place. Review of Resident #19's progress note, dated 1/16/25 and created by Nurse #1, indicated but was not limited to: -At approximately 7:45 P.M., Resident #19 was observed sitting in front of his/her wheelchair, stating that he/she slipped out of the chair because the Dycem had been stolen from his/her room. -Dycem was applied to the wheelchair after he/she was observed on the floor. During an interview on 3/6/25 at 12:29 P.M., Nurse #2 said Resident #19 had multiple falls and the interventions to prevent further falls were listed on his/her MAR to inform the nurses of his/her safety precautions. Nurse #2 said one of Resident #19's interventions included Dycem to his/her wheelchair. During a telephonic interview on 3/6/25 at 11:52 A.M., Nurse #1 said she was the Nurse assigned to Resident #19 on 1/16/25 when he/she sustained a fall. Nurse #1 said Resident #19 told her the Dycem was missing from his/her wheelchair and when she checked the wheelchair the Dycem was not in place. Nurse #1 said she tried to contact the rehabilitation department to get more Dycem for Resident #19, but nobody was there and she was unable to get more Dycem at that time. Nurse #1 said later in the shift, Resident #19 fell from his/her wheelchair. During an interview on 3/10/25 at 8:35 A.M., Resident #19 said the day he/she fell from their wheelchair, the facility staff was aware the Dycem was missing because he/she had told them it was missing from his/her wheelchair. Resident #19 said the Dycem had been missing for a day or so. During an interview on 3/6/25 at 4:08 P.M., Nurse #5 said when Resident #19 fell on [DATE] at approximately 7:45 P.M., she did not see the Dycem on the wheelchair. During an interview on 3/10/25 at 11:01 A.M., the Director of Nurses (DON) said Resident #19 had several falls and often would refuse interventions and would remove the Dycem from his/her wheelchair at times. The DON said that if the management team was made aware that the Dycem was not in place on 1/16/25, they would have ensured that it was reapplied to promote safety and prevent falls. 2. Resident #48 was admitted to the facility in April 2022 with diagnoses including adult failure to thrive, malnutrition and legal blindness. Review of the MDS assessment, dated 12/18/24, indicated Resident #48 had moderate cognitive impairment as evidenced by a BIMS score of 12 out of 15. Further review of the MDS assessment indicated he/she received setup or clean-up assistance when eating. Review of Resident #48's current Physician's Orders included but was not limited to: -Please provide 1:1 assist and encouragement with meals, dated 11/6/24 Review of Resident #48's nursing progress note, dated 11/4/24, indicated nursing assisted the resident with dinner and he/she ate 100% of soup, drank 100% of his/her milkshake, ate pie that his/her son had provided and a chocolate candy bar. Further review of the progress note indicated that Resident #48 was typically just a set-up for meals but would benefit from 1:1 feeding. Review of Resident #48's Provider Encounter Note, dated 11/6/24, indicated but was not limited to: -Review of Systems: Patient would benefit from 1:1 assistance with meals -Assessment/Plan: Adult failure to thrive syndrome: Will request 1:1 assistance at meals as he/she eats better when he/she is assisted -Discussion Notes: Nursing reporting he/she does better with meals with assistance and encouragement. Will request that he/she be provided with 1:1 assist at meals Review of Resident #48's Provider Encounter Note, dated 12/6/24, indicated but was not limited to: -Review of Systems: Patient would benefit from 1:1 assistance at meals. Now receiving assistance for meals -Assessment/Plan: Discussed on-going need for assistance at meals with nursing. Son concerned that he/she had been eating well and is now not eating. On the following dates and times of survey, the surveyor observed Resident #48 alone in his/her room eating a meal: -3/4/25 at 8:45 A.M. -3/5/25 at 12:12 P.M. -3/6/25 at 8:28 A.M. -3/6/25 at 12:26 P.M., and -3/10/25 at 8:32 A.M. Review of the March 2025 Medication Administration Record (MAR) indicated but was not limited to: -On March 4th, 5th, and 6th, the nursing staff had signed the order acknowledging Resident #48 had required 1:1 assistance and encouragement with meals. During an interview on 3/6/25 at 2:12 P.M., Certified Nursing Assistant (CNA) #1 said Resident #48 required set-up assistance for meals and to be oriented to his/her tray because he/she was legally blind. CNA #1 said Resident #48 did not receive 1:1 assistance with meals. During an interview on 3/6/25 at 12:31 P.M., Nurse #2 said Resident #48 was a very picky eater and his/her intake depended on his/her mood. Nurse #2 said Resident #48 needed set-up assistance and to be told where everything on his/her plate was because he/she was legally blind, but he/she did not need 1:1 assistance with meals. During an interview on 3/6/25 at 1:49 P.M., Nurse #4 said the Nurse Practitioner wrote the order for 1:1 assistance and encouragement with meals because Resident #48's intake would be improved. During an interview on 3/6/25 at 2:04 P.M., Nurse Practitioner #1 said she wrote the order for Resident #48 to have 1:1 encouragement and assistance with meals because he/she was losing weight and does much better with encouragement. Nurse Practitioner #1 said she spoke with nursing at the time who said when said when Resident #48 was assisted with meals he/she would consume most of their meal. During an interview on 3/10/25 at 11:01 A.M., the Director of Nurses (DON) said the order for 1:1 assistance with meals for Resident #48 was not initiated because he/she was at risk for aspiration, but because he/she was legally blind. The DON said that staff would orient the resident to his/her tray and he/she was able to feed himself/herself.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was complete and accurate to reflect the status of one Resident (#27), out of a sample of 15 residents. Specifically, the facility failed: a. To ensure an MDS was accurately coded for a fall with major injury, and b. To ensure the use of a bed alarm was accurately coded on all MDS assessments. Findings include: The facility's policy titled Policy and Procedures within the Nursing Documentation Department for MDS, revised 12/2024, indicated but was not limited to the following: -The RAI (Resident Assessment Instrument) manual is our policy and procedure manual for MDS. Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, indicated but was not limited to the following: 1) J1800: Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA (Omnibus Budget Reconciliation Act) or Scheduled PPS (Prospective Payment System)), whichever is more recent -If this is not the first assessment/entry or reentry, the review period is from the day after the ARD (Assessment Reference Date) of the last MDS assessment to the ARD of the current assessment. -Code 0, no: if the resident has not had any fall since the last assessment. -Code 1, yes: if the resident has fallen since the last assessment. Continue to Number of Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS) item (J1900), whichever is more recent. 2) P0200: Alarms -An alarm is any physical or electronic device that monitors resident movement and alerts the staff, by either audible or inaudible means, when movement is detected, and may include bed, chair and floor sensor pads, cords that clip to the resident's clothing, motion sensors, door alarms, or elopement/wandering devices. -Code 0, not used: if the device was not used during the 7-day look-back period. -Code 1, used less than daily: if the device was used less than daily. -Code 2, used daily: if the device was used on a daily basis during the look-back period. a. Resident #27 was admitted to the facility in July 2024 with diagnoses including dementia and traumatic subdural hemorrhage (bleeding in the space around the brain after a head injury. Review of Resident #27's medical record indicated that the Resident sustained a fall on 12/21/24. The Resident required transfer to the hospital for further evaluation. Imaging completed at the hospital indicated the Resident had age-indeterminate right fifth and seventh rib fractures and likely acute compression fractures of the thoracic spine (T1 through T3). The facility reported the fall with injury to the Massachusetts Department of Public Health via the Health Care Facility Reporting System (HCFRS). Review of the most recent MDS assessment, dated 1/22/25, indicated but was not limited to the following: -Section J - Health Conditions J1800. Has the resident had any falls since admission or the prior assessment (OBRA or PPS), whichever is more recent? No During an interview on 3/10/25 at 12:46 P.M., the MDS Nurse said that Resident #27's medical record did indicate the Resident sustained a fall on 12/21/24. The MDS Nurse said that the fall with major injury should have been coded on the Resident's 1/22/25 MDS assessment but was not. b. Review of Resident #27's current Physician's Orders indicated but was not limited to the following: -Alarms: *Bed Alarm* Ensure alarm is on and functioning every shift (order date 7/30/24) Review of Resident #27's Care Plan indicated but was not limited to the following: Problem: Resident is at risk for falls due to: decreased mobility I fell on [DATE] trying to put my slippers on and did not call for assistance Approach: Evaluate need for bed alarm was applied after my fall 7/29/24. Please ensure it is in place and working correctly (approach start date 7/29/24) Review of Section P (Restraints) of the Resident #27's MDS assessments, dated 8/4/24, 11/1/24, and 1/22/25, indicated that a bed alarm was not used. During an interview on 3/10/25 at 11:38 A.M., Nurse #3 said that Resident #27 utilizes bed and chair alarms as part of his/her fall prevention care plan. During an interview on 3/10/25 at 12:34 P.M., the Director of Nurses said that Resident #27 utilizes bed and chair alarms. During an interview on 3/10/25 at 12:46 P.M., the MDS Nurse said that Resident #27 had an order in place for a bed alarm since July 2024 and the alarm should have been coded on the Resident's 8/4/24, 11/1/24, and 1/22/25 MDS assessments.

Based on observation, interview, and policy review, the facility failed to ensure staff stored and properly labeled all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to: 1. Ensure staff properly labeled all drugs and biologicals stored in 2 of 4 medication carts once opened; and 2. Ensure staff safely and securely stored all medications in 1 of 2 medication storage rooms and 2 of 4 medication carts. Findings include: Review of the facility's policy titled Medication Storage in the Facility, revised [DATE], indicated but was not limited to the following: -Medication rooms, carts, and medication supplies are locked when not in use or in direct view of persons with authorized access. -All medications dispensed by the pharmacy are stored in the container with the pharmacy label. -Certain medications or package types, such as multiple dose injectable vials, ophthalmics, once opened, require an expiration date shorter than the manufacturer's expiration date to ensure medication purity and potency. -When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication (if dedicated area not on label/container and enter the date opened and the new date of expiration). The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating (see Appendix 5-Medications with Shortened Expiration Dates). Review of the facility's policy titled, Medications with Shortened Expiration Dates, revised [DATE], indicated but was not limited to the following: -Lantus Solostar (insulin glargine) (injection that helps manage blood sugar levels) pen, 28 days from open or out of refrigerator -Novolog (insulin aspart) (injection used to treat diabetes) flexpen, 28 days from open or out of refrigerator -Fluticasone Propionate HFA (nasal spray used to relieve seasonal and year-round allergic and non-allergic nasal symptoms), 12 months from open -Refresh eye drops (soothes and relieves eyes from dryness), 90 days from open 1a. 2nd Floor Medication Cart, A-Side On [DATE] at 8:04 A.M., the surveyor reviewed the 2nd floor medication cart, A-Side, with Nurse #3 and observed the following: One Lantus Solostar kwik pen, 100 units (U)/milliliter (ml) -seal broken indicating it had been used, not in packaging container -not labeled with the minimum including the medication name (generic and/or brand), prescribed dose, strength, the resident's name, and route of administration along with appropriate instructions and precautions -not labeled with the date opened or shortened expiration date One bottle of Refresh liquigel lubricant eye drops, 0.5 fluid (f) ounces (oz.), 15 ml, inside the packaging box -packaging box opened; bottle's seal broken -packaging box and bottle not labeled with the date opened or shortened expiration date During an interview on [DATE] at 8:04 A.M., Nurse #3 said the Lantus Solostar pen had been used for a resident but was not labeled. She said although it was in a compartment assigned to a specific resident's room number, she could not be sure that it was the resident's if it did not have a pharmacy label on it. Nurse #3 said it should have been labeled with the resident's name, dose, date opened, and the date when it expires. She said she could not be sure but thought it expired 28 days after opening. Nurse #3 also said the Refresh eye drops had been used for a resident and should have been labeled with the date when opened and the expiration date. She said she wasn't sure but thought it was good for 30 days. b. 3rd Floor Medication Cart, A-Side On [DATE] at 8:58 A.M., the surveyor reviewed the 3rd floor medication cart, A-Side, with Nurse #2 and observed the following: One bottle of Refresh liquigel lubricant eye drops, 0.5 fluid oz., 15 ml, inside the packaging box -packaging box opened; bottle's seal broken -packaging box and bottle not labeled with the date opened or shortened expiration date One Novolog flexpen -seal broken, not in packaging container -not labeled with the date when opened or shortened expiration date Two bottles of Fluticasone Propionate HFA nasal spray, 50 micrograms -not labeled with the dates when opened or shortened expiration dates During an interview on [DATE] at 8:58 A.M., Nurse #2 said the medications had all been used and should have been labeled with the dates when opened and new expiration dates. She said the Refresh eye drops and Novolog flex pen were only good for 28 days after opening and the nasal spray was good for 60 days after opening. 2a. On [DATE] at 2:07 P.M. and 3:16 P.M., the surveyor observed the 3rd floor medication room door unlocked, opened, and unattended by staff. No staff were in direct view of the medication room. b. On [DATE] at 8:18 A.M., the surveyor observed the top drawer of the 2nd floor medication cart, B-Side, to be slightly open. No staff were present or in direct sight of the cart. The surveyor was able to open the top drawer of the medication cart where various over the counter medications were stored. The remaining drawers were in the locked position. Nurse #13 approached the cart approximately one minute later. During an interview on [DATE] at 8:22 A.M., Nurse #13 said she was assigned to the cart and said it was locked that she knew of, but maybe the top drawer wasn't closed all the way prior to the cart being locked. Nurse #13 said regardless, all the drawers should have been locked when unattended. 31830 c. On [DATE] at 11:50 A.M., the surveyor observed a medication cart parked on the backside of the 2nd floor unit unlocked and unattended, which resulted in the surveyor having access to the medication cart contents. At 11:51 A.M., the surveyor observed Nurse #1 exit from the rest room near the medication cart and walk past the medication cart into the dining room. Nurse #1 returned to the medication cart for a bottle of hand sanitizer which was on the top of the cart for another staff member, and then left the area. The medication cart remained unlocked and unattended. At 11:52 A.M., Staff Member #1 walked on to the unit and stood near the medication cart with the surveyor. At 11:55 A.M., Unit Manager #1 walked up to the medication cart and locked the cart. During an interview on [DATE] at 11:56 A.M., Unit Manager #1 said when the medication cart was not in use, the cart should be brought to the front of the unit where it could be observed and supervised at all times. Unit Manager #1 said the medication cart should always be locked when not in attendance by a nurse. During an interview on [DATE] at 11:58 A.M., Nurse #1 said the medication cart should always be locked. During an interview on [DATE] at 9:58 A.M., the Director of Nursing (DON) said once medications are opened, staff need to label them with the date when opened and the expiration date. She said multiuse medications including insulins, eye drops, and nasal sprays all had shortened expirations with the purpose being for stabilization of the medications and they would only be good for a certain time. She said the Lantus Solostar pen would only be good for 28 days and should have had a pharmacy label on it, the Refresh eye drops were only good for 90 days after opening, and the Fluticasone nasal spray was good for 12 months after opening. She said the expectation was for staff to label the outside of the packaging box as well as the contents inside, but it's been a constant battle with staff to do this. The DON said the medication carts and medication storage rooms should be locked when unattended and, even if there's mechanical failure, it was still up to the nurses to ensure safe and secure storage.

Based on observation, interview, and test tray results, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, multiple residents voiced concerns regarding the quality and temperatures of the food provided by the facility. Findings include: During the initial tour of the 3rd floor unit on 1/11/24 at 10:30 A.M., multiple residents voiced complaints regarding the palatability of their meals as follows: -Resident #11 described the food as Iffy and not to his/her satisfaction. -Resident #50 said that the Food leaves little to be desired. -Resident #19 complained that the food is not always warm. -Resident #36 said the food's cold. -Resident #41 said The food is not always warm. That's my only complaint. During an interview on 1/10/24 at 4:42 P.M., the Ombudsman said that he frequently received complaints from residents regarding the temperatures and the quality of the food. During the Resident Group Meeting on 1/12/24 at 1:33 P.M., attended by 17 residents, many of the residents voiced complaints that the food was not great, sometimes terrible, and the flavor of the food was not always appealing. On 1/16/24, on the 3rd floor, the surveyor conducted a test tray of the lunch meal. At 12:09 P.M., the test tray was placed in the food truck and transported to the 3rd floor. At 12:23 P.M., the test tray (last tray) was removed from the food truck and immediately tested by the surveyor and the Food Service Supervisor (FSS). The test tray results were as follows: -Balsamic chicken-100 degrees Fahrenheit (F), tepid and dry to taste. -Mixed vegetables-120 degrees F, lukewarm and acceptable to taste -Rice-100 degrees F, tepid and bland to taste. -Milk-50 degrees F, cool to taste (not cold). During an interview on 1/16/24 at 12:30 P.M., the FSS said that the test tray temperatures/palatability should have been warmer and more appealing. On 1/17/24, on the 3rd floor, the surveyor conducted a test tray of the breakfast meal. At 8:12 A.M., the test tray was placed in the food truck and left the kitchen. The truck arrived on the 3rd floor at 8:15 A.M. At 8:33 A.M., the test tray (last tray) was removed from the food truck and immediately tested by the surveyor and FSS. The test tray results were as follows: -Scrambled eggs- 109 degrees F, tepid and bland to taste. -Sausage-109 degrees F, tepid to taste, taste satisfactory -Cream of wheat-117 degrees F, lukewarm and acceptable to taste -Orange juice-48 degrees F, cool to taste (not cold) -Milk-50 degrees F, cool to taste (not cold) -Coffee-142 degrees F, hot to taste During an interview on 1/17/24 at 8:40 A.M., the FSS said that the test tray temperatures and palatability of the meal were not acceptable. She said that the delay in staff distributing the meal trays to residents timely contributed to the unsatisfactory meal temperatures/palatability of the meal.

Based on observation, interview, and policy review, the facility failed to ensure staff maintained an infection control program designed to provide a safe and sanitary environment to help prevent the development and potential spread of infections. Specifically, the facility failed to: 1. Ensure staff properly performed hand washing during COVID-19 testing to prevent the potential spread of infection; and 2. Ensure staff prepared and administered medications in a safe and sanitary manner. Findings include: 1. Review of the facility's Anterior Nasal Swab Collection Competency Skills, undated, indicated but was not limited to the following: - Disinfect the surface where you will open the collection. Remove and lay out content of the kit. - Wash hands with soap and water. If soap and water are not available, use hand sanitizer. - Remove the swab from the package. Do not touch the soft end with your hands or anything else. - Insert the entire soft end of the swab into your nostril no more 3/4 of an inch into your nose. - Slowly rotate the swab, gently pressing against the inside of your nostril at least four times for a total of 15 seconds. Get as much nasal discharge as possible on the soft end of the swab. - Using the same swab, repeat the steps in the other nostril with the same end of the swab. - Insert the swab into bottom hole and firmly push upwards so that the swab tip is visible in the top hole. - Rotate swab shaft three times to the right. Do not remove swab. - Peel off adhesive liner from the right edge of the test card. Read the result in the window 15 minutes after closing. - Appropriately wash with soap and water or use hand sanitizer if soap and water is not available, when done. On 1/12/24 from 7:04 A.M. to 8:00 A.M., the surveyor observed four nurses and seven Certified Nursing Assistants (CNA) fail to perform hand hygiene before and after self-Binax-Now testing for COVID-19. The surveyor observed that Staff #1, recording the results, did not perform hand hygiene after touching the dirty testing cards. On 1/12/24 from 2:45 P.M. to 3:16 P.M., the surveyor observed four nurses, and nine CNAs fail to perform hand hygiene before and after self- Binax-Now testing for COVID-19. The surveyor observed that Staff #1, recording the results, did not perform hand hygiene after touching the dirty testing cards. On 1/16/24 from 2:45 P.M. to 3:16P.M., the surveyor observed three nurses and seven CNAs fail to perform hand hygiene after self- Binax-Now testing for COVID-19. On 1/16/24 from 4:08 P.M. to 4:28 P.M., the surveyor observed one CNA and three dietary aides fail to perform hand hygiene before and after self- Binax-Now testing for COVID-19. During an interview on 1/17/24 at 10:39 A.M., the infection control preventionist said upon arrival to the front lobby, staff are to perform hand hygiene, apply mask, sign in, then perform the self- Binax-Now testing. She said her expectation is that staff should not be handling contaminated Binax-Now cards without sanitizing their hands and/or wearing gloves. She said the policy is to wash your hands before and after testing, and after discarding the dirty Binax-Now cards. 42742 2. On 1/16/24 at 7:54 A.M., the surveyor observed Nurse #4 preparing medications for a resident. Nurse #4 tore open the plastic medication packet to access the contents inside and, while doing so, one medication tablet fell out of the packet and onto the top of her medication cart. Nurse #4 used the outer surface of the packet to pick up the tablet. She then placed it into a medication cup and administered it to the resident. During an interview on 1/16/24 at 8:17 A.M., Nurse #4 said she should have disposed of the medication tablet and gotten a new one to avoid potential cross-contamination from the outer packaging and/or top of her medication cart. During an interview on 1/17/24 at 9:00 A.M., the Infection Preventionist (IP) said Nurse #4 should have used a paper towel on the top of her medication cart because the facility was using a new pharmacy with a whole new process and pills could drop out of the medication packets. She said because of this, staff should use a napkin or something on top of the cart in case that happens. The IP said Nurse #4 should not have used the outside surface of the packaging and should have worn gloves. She said she could not guarantee the top of the medication cart was disinfected prior and that's why nurses should use the paper towel per the pharmacy's suggestion. During an interview on 1/17/24 at 9:54 A.M., the Director of Nursing (DON) said if pills fall out of the medication packets and onto the top of the medication cart they should be discarded, and another tablet obtained.

Based on observation and interview, the facility failed to ensure residents in one of four dining rooms experienced a comfortable and homelike dining experience. Findings include: During dining observations made on 1/11/24 and 1/12/24, the surveyors observed the following in the dining areas: On 1/11/24 at 8:41 A.M., the surveyor observed five residents seated in wheelchairs in the third-floor dining room. - Two residents were seated at a table facing the wall and a television, which was tuned into a news station. - Two residents were seated at a table on the opposite side of the room, facing the wall. - One resident was seated at a table in the middle of the room, facing out towards the window. - All residents were seated with their backs to each other. - All meals were served on trays to all the residents. - One staff member was observed to be checking their cell phone when the surveyor entered the dining room. On 1/11/24 at 12:05 P.M., the surveyor observed nine residents seated in wheelchairs in the third-floor dining room. - Two residents were seated at a table facing the wall and a television, which was tuned into a news station. - Two residents were seated at a table on the opposite side of the room, facing towards the wall, with lunch meals served on trays - Three residents were seated at a table in the middle of the room. One resident was facing out toward the window with the lunch meal served on the tray. One resident was facing out toward the room and was assisted by a staff member to eat the lunch meal. One resident was facing out toward the room without a lunch meal in place. - Two residents were seated at a table behind the door, facing the wall without lunch meals in place. During an interview on 1/11/24 at 12:06 P.M., Certified Nurse Aide (CNA) #2 said the two residents seated behind the door had lunch meals which arrived on the second food truck. CNA #2 said the staff tried to separate residents in the dining room who required assistance with feeding so not all trays arrived on the unit at the same time. On 1/11/24 at 12:25 P.M., the surveyor observed the main dining room. -There were residents seated at five tables with glass tops and tablecloths. - All residents were served lunch by staff from the steam table, all meals were removed from trays and plates were placed in front of all residents. - All residents were seated around the table, facing each other. - Staff were observed walking throughout the dining room, assisting residents as needed. - The dining room was observed to be nicely decorated with pleasant music playing in the background. On 1/12/24 at 11:57 A.M., the surveyor observed six residents seated in wheelchairs in the third-floor dining room. - Two residents were seated at a table facing the wall and a television, which was tuned into a news station. One resident was eating lunch, while the other resident waited for their lunch. - One resident was seated at the table behind the door without a lunch meal. - One resident was seated at the table in the middle of the room and was being assisted by a staff member to eat the lunch meal. - Two residents were seated at the table on the opposite side of the room, facing towards the wall without lunch meals. During an interview on 1/12/24 at 12:32 P.M., the Staff Development Educator said the dining environment in the third-floor dining room was not homelike as several residents were without lunch trays as other residents ate their lunch. The Staff Development Educator said the third floor Unit Manager recently left the position which attributed to the current dining experience for the residents. During an interview on 1/18/24 at 3:15 P.M., the Administrator was made aware of the surveyor's observations of the dining experience provided to the residents. The Administrator said all residents should be provided with a homelike, comfortable, and dignified experience.

Based on record review, policy review, and staff interview, the facility failed to develop a comprehensive person-centered care plan for two Residents (#22 and #55), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #22, to ensure staff developed a care plan for the Resident's use of an external catheter device (condom catheter) (urinary collection device with a tube that goes to a collection bag); and 2. For Resident #55, to ensure staff developed a care plan that addressed a cancerous lesion on the Resident's left forearm. Findings include: Review of the facility's policy titled Comprehensive Care Plan, revised July 2023, indicated but was not limited to the following: -All homes will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident right that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. -The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being as required. -A comprehensive care plan must be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessment. 1. Resident #22 was admitted to the facility in July 2023 with diagnoses including urinary retention, benign prostatic hypertension (prostate gland enlargement that can cause urination difficulty), chronic kidney disease, urinary tract infection, and left ureteral stent placement in 2020. Review of the Minimum Data Set (MDS) assessment, dated 10/10/23, indicated Resident #22 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15 and had an indwelling catheter device (a soft tube that is inserted into the bladder to drain the urine). Review of Physician's Orders indicated the following: -Apply condom catheter at bedtime once a day at 19:00 (7:00 P.M.), 12/8/23 -Condom catheter applied daily at 7:00 P.M., to remain on 24 hours daily, changed daily at 7:00 P.M., 1/4/24 Review of the January 2024 Medication Administration Record (MAR) indicated Resident #22's condom catheter was applied at 7:00 P.M. for 15 out of 15 days. Review of Resident #22's comprehensive care plans failed to include any documented evidence that the facility developed a care plan which addressed the Resident's current use of a condom catheter along with measurable objectives and timeframes to meet the Resident's needs. During an interview on 1/17/24 at 3:23 P.M., the surveyor reviewed the medical record with Nurse #5 who said Resident #22 used to have a Foley catheter but now has a condom catheter. She said there was no care plan in place for the use of the condom catheter but there should be. During an interview on 1/18/24 at 8:45 A.M., Unit Manager (UM) #1 said the order for the condom catheter was placed on 12/8/23 and should have been care planned by now but wasn't. During an interview on 1/18/24 at 1:20 P.M., the Director of Nursing (DON) said there wasn't a care plan developed for the condom catheter but should have been and the UM was ultimately responsible for initiating it. 2. Resident #55 was admitted to the facility in December 2022 and had diagnoses including malignant neoplasm of bronchus or lung, secondary neoplasm of the lung, and malignant neoplasm of the pancreas. Review of Resident #55's Physician's Progress Note, dated 12/27/22, indicated Resident #55 had a suspicious lesion on his/her left forearm and had a dermatology appointment scheduled. Review of the MDS assessment, dated 10/4/23, indicated Resident #55 had moderate cognitive impairment as evidenced by a BIMS score of 12 out of 15. During an observation with interview on 1/11/24 at 12:26 P.M., the surveyor observed a large oval, crusted, discolored, and raised area on the Resident's left forearm approximately 4 inches in length x 3 inches wide. The lesion was uncovered and open to air. Resident #55 said the area was a sore and had been there a while, about a year. Review of Physician's Orders indicated the following: -Left upper extremity normal saline wash, pat dry followed by bacitracin twice a day, 9/28/23 Review of a Skin Note, dated 12/25/23, indicated Resident #55 had a dried, cancerous area to the left forearm. Review of Resident #55's comprehensive care plans failed to include any documented evidence that the facility developed a care plan which addressed the lesion on the Resident's left forearm along with measurable objectives and timeframes to meet the Resident's needs. During an interview on 1/17/24 at 3:18 P.M., Nurse #5 said Resident #55 had a cancerous tumor on his/her left forearm and was receiving wound treatments. During an interview on 1/18/24 at 12:03 P.M, the surveyor reviewed Resident #55's medical record with UM #1 who said there wasn't a care plan for the Resident's lesion but there should be. She said the care plan would have included the problem identified, goals, interventions, and how they would evaluate or assess outcomes. During an interview on 1/18/24 at 1:14 P.M., the DON said the lesion should have been care planned but was not.

Based on policy review, record review, and interview, the facility failed to provide written notification of the bed hold policy to the Resident and/or Resident Representative prior to transfer to the hospital for one Resident (#32), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled Bed Hold and Notice, undated, indicated but was not limited to: - Residents on Medicaid are entitled when they are transferred to a hospital or for medical leave of absence. - During this period, the resident is permitted to return and resume residence in the facility. Resident #32 was admitted to the facility in April 2023 with diagnoses which included anemia, cerebral infarction, type two diabetes mellitus, and chronic obstructive pulmonary disease. Review of the electronic medical record census history indicated Resident #32 was transferred to the Hospital Emergency as followed: 6/27/23 change in condition displayed signs and symptoms of congested lung sounds, 11/24/23 medical leave of absence (MLOA) admitted to the hospital after planned paracentesis; 11/27/23 Resident displayed signs and symptoms of abdominal pain while at a GI appointment and was transferred to an acute care hospital for an evaluation; and 12/26/23 Resident's weekly laboratory (hemoglobin) results were abnormal, new order obtained to transfer to an acute care hospital for evaluation and possible admission. During an interview on 1/18/24 at 12:37 P.M., Unit Manager #1 said nurses should know about the process of bed hold. Unit Manager #1 said the bed hold policy and notice were not done in this case. During an interview on 01/18/24 at 2:13 P.M., the Social Worker said nurses are responsible for completing a bed hold. The Social Worker said the bed holds were not done for Resident #32. During an interview on 01/18/24 at 3:24 P.M., the Director of Nurses said she was not aware the bed holds were not provided to Resident #32 and/or their Resident Representative.

Based on record review, policy review, and interview, the facility failed to ensure written notice for transfer and discharge was provided to the Resident and/or Resident Representative prior to hospital transfer for one Resident (#32), out of a total sample of 19 residents. Findings include: Review of the facility's policy titled 30 Day Notice of Intent to Transfer or Discharge Resident and Discharges, revised 07/15, indicated the following: -The transfer or discharge is necessary to meet the resident's welfare, and the resident's welfare cannot be met in the facility as documented by the resident's physician. Review of the medical record indicated Resident #32 was admitted to the facility in April 2023 with diagnoses which included anemia, cerebral infarction (stroke), type two diabetes mellitus, and chronic obstructive pulmonary disease. Review of the most recent Minimum Data Set (MDS) assessment, dated 1/17/24, indicated Resident #32 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Review of the electronic medical record census history indicated Resident #32 was transferred to the Hospital Emergency as followed: 6/27/23 change in condition exhibiting signs and symptoms of congested lung sounds; 11/27/23 Resident displayed signs and symptoms of abdominal pain while at a GI appointment and was transferred to an acute care hospital for an evaluation; and 12/26/23 Resident's weekly laboratory (hemoglobin) results were abnormal, new order obtained to transfer to an acute care hospital for evaluation and possible admission. Further review of the medical record failed to indicate a Notice of Transfer/Discharge was issued for each transfer to Resident #32 or his/her Representative. During an interview on 1/18/24 at 12:37 P.M., Unit Manager #1 said the Notice of Transfer/Discharge should be done when a resident is sent to the hospital and in this case, they were not done.

Based on interviews and records reviewed, for two of three sampled residents (Residents #1 and #2) the Facility failed to ensure staff consistently implemented the Facility Abuse Prohibition Policy when Nurse #2 observed a potentially sexually inappropriate interaction between the two residents, and did not immediately separated them. On 9/15/23, Nurse #2 saw Resident #1 in Resident #2's room, standing at Resident #2's bedside holding up Resident #2's leg. Resident #2 who was in bed, was not wearing an incontinence brief, and the lower half of his/her body was not covered by a sheet or a blanket, therefore leaving him/her exposed. Nurse #2 did not immediately separate Resident #1 and Resident #2, in accordance with Facility Policy, and did not attempt to remove Resident #1 from Resident #2's room at that time, but instead went to the nurses station and asked Nurse #1 for help, therefore leaving Resident #2 at risk for potential for abuse. Findings include: The Facility Abuse Prohibition Policy and Procedure, undated, indicated that residents would be immediately protected from alleged abuse. Review of Resident #1's most recent Minimum Data Set Assessment, dated 7/18/23, indicated his/her memory skills were intact. Review of Resident #2's most recent Minimum Data Set Assessment, dated 8/08/23, indicated his/her memory skills were impaired. Review of the report submitted by the Facility via the Health Care Facility Reporting System, dated 9/15/23, indicated the Charge Nurse (Nurse #2) reported she walked by Resident #2's room and observed Resident #1 (who was in his/her wheelchair) sitting close to Resident #2, who was lying in bed. The Report indicated Resident #1 was observed holding up Resident #2's leg, and Resident #2's brief was off and laying on the bed. The Report indicated that when Resident #1 was asked what he/she was doing, that he/she replied I know I was wrong but I did not have sex with him/her, I was kissing him/her goodbye, and that Resident #1 then started to cry. The Report further indicated that Resident #1 was immediately removed from the room. However, further review of the HCFRS report and documentation submitted by the facility as part of their internal investigation, which included written witness statements from the Charge Nurse (Nurse #2 ) and Nurse #1, who worked the evening shift on 9/15/32, indicated there was conflicting information regarding the facility's report that the residents were immediately separated. Review of Nurse #2's (who was the Charge Nurse that evening) written Witness Statement, dated 9/15/23, indicated she was walking in the hallway by Resident #2's room and saw Resident #1 sitting in his/her wheelchair close to Resident #2, who was in bed. The Statement indicated Resident #2 was on his/her back with no covers on and his/her incontinent brief was in the bed. The Statement indicated she (Nurse #2) saw Resident #1 holding Resident #2's leg up in the air. The Statement further indicated that she (Nurse #2) was very upset and went to get the other nurse (Nurse #1) and when they (Nurse #2 and #1) arrived at Resident #2's room, Resident #1 was wheeling him/herself out of the room and was crying. Review of Nurse #1's written Witness Statement, dated 9/15/23, indicated that Nurse #2 came to her (Nurse #1) and stated words to the effect of, come see what I just saw. The Statement indicated that she (Nurse #1) immediately went with the other nurse (Nurse #2) to Resident #2's room, and that Resident #1 was wheeling him/herself out of the room and was crying. During an interview on 10/17/23 at 3:15 P.M., Nurse #2 said that on 9/15/23, (during the 3:00 P.M. to 11:00 P.M. shift) when she walked passed Resident #2's room she saw Resident #1 at Resident #2's bedside, close to the bed. Nurse #2 said that Resident #2 was in bed on his/her back, he/she was dressed in a house gown (johnny) with nothing (no sheet or blanket) else covering him/her and he/she was not wearing an incontinence brief. Nurse #2 said that Resident #1 was holding Resident #2's leg (had his/her hands on Resident #2's lower leg) and was lifting Resident #2's leg off the mattress. Nurse #2 said that she asked Resident #1 what he/she was doing and that Resident #1 said words to the effect of he/she was kissing Resident #2 goodnight. Nurse #2 said she left Resident #2's room (leaving Resident #1 in Resident #2's room) and went to get Nurse #1. During an interview on 10/12/23 at 3:50 P.M., Nurse #1 said that on 9/15/23 at approximately 8:10 P.M. Nurse #2 approached her at the nurses station and asked for her help. Nurse #1 said that she followed Nurse #2 to Resident #2's room and observed Resident #1 exiting Resident #2's room. Nurse #1 said that Resident #2 was attempting to get out of bed and that she noted Resident #2's incontinence brief was laying on his/her bed. Review of the Facility's Floor Plan for the third floor Unit where Residents #1 and #2 resided indicated that the Unit consisted of two parallel corridors with a hallway between them where the nurses station was located. The Floor Plan indicated that Resident #2's room was at the far end of one of the corridors. The Floor Plan indicated that the path from Resident #2's room to the nurses station required walking past two other resident rooms, turning right and passing the elevator, the elevator lobby and the activity room, before reaching the nurses station. During an interview on 10/17/23 at 11:30 A.M., the Director of Facility Operations said that the approximate distance between Resident #2's room and the nurses station was 73 feet. During an interview with the Director of Nurses (DON) on 10/17/23 at 12:15 P.M., said the expectation of staff is that they implement and follow the facility abuse policy. The DON said that on 9/15/23, she interviewed Nurse #2 about the incident in which Resident #1 was at Resident #2's bedside. The Director of Nurses said that Nurse #2 told her that after finding Resident #1 at Resident #2's bedside, she separated them. However this was inconsistent with the Nurse #2's and Nurse #1's written witness statement and interviews, during which they both indicated that instead of immediately separating Resident #1 and Resident #2, Nurse #2 went to the nursing station and asked Nurse #1 for help, and they went Resident #2's room together.

Based on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to: 1) Ensure that during a facility outbreak of COVID-19, the use of personal protective equipment (PPE), including eye protection, gowns, and gloves, were being used for high contact patient care per facility policy; and 2) Ensure that COVID-19 PCR (polymerase chain reaction) outbreak testing was conducted in a manner that is consistent with current standards of practice established by State and Federal agencies to maintain proper infection control and follow universal precautions for testing material. Findings include: Review of the facility's policy titled Policies & Procedures during the COVID-19 Outbreak, undated, indicated the following: -The facility follows the guidelines of the Department of Public Health (DPH), CDC (Centers for Disease Control and Prevention), and CMS (Centers for Medicare and Medicaid Services) regarding COVID-19. Review of the DPH Memorandum, titled Update to Caring for Long-Term care Residents during the COVID-19 Response, dated 1/25/22 indicated the following: -Personal Protective Equipment: -Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with residents and in alignment with DPH and CDC guidance. All long-term care facility personnel should wear a facemask while they are in the facility and eye protection during resident encounters. -Full PPE, including N95 respirator or alternative, eye protection, gloves, and gown, should be worn per DPH and CDC guidelines for the care of any resident with known or suspected COVID-19. If any resident (not in quarantine due to being a new admission) or staff are confirmed to be COVID-19 positive within the past fourteen days, healthcare personnel should wear gowns and gloves for high contact care of all residents who are not up to date with COVID-19 vaccine or recovered from COVID-19 in the last 90 days, on affected units. 1) During an interview on 2/16/22 at 8:14 A.M., the Infection Preventionist (IP) said the facility staff is expected to wear a surgical mask only on the units and during patient care. During an interview on 2/16/22 at 11:28 A.M., the IP said the most recent staff member to test positive for COVID-19 was on 2/10/22. The IP said the positive staff member worked as a staff nurse on Unit 2 on 2/9/22, and was considered to have provided direct patient care, including the administration of medications and treatments, just seven days prior. A facility is considered in a COVID-19 outbreak when one or more new staff or resident case is identified within the facility within the past 14 days. During the initial screening process on 2/16/22, the surveyors observed the following: - On 02/16/22 at 10:05 A.M., the surveyor observed two facility staff members wearing surgical masks (no face shield) on Unit 2, near room [ROOM NUMBER]. The two staff were observed entering and exiting resident rooms. Upon exiting room [ROOM NUMBER] neither staff members were observed performing hand hygiene. The hand sanitizer, attached to the wall near room [ROOM NUMBER] was empty of anti-bacterial sanitizer. - On 02/16/22 at 10:30 A.M., the surveyor observed two facility staff members wearing surgical masks (no face shields, no gowns, and no gloves) transfer a Resident from a wheelchair to a stationary chair. The two staff were observed providing physical assistance and direct contact with the Resident. After, the Resident was placed in the chair, the two staff lifted the Resident and placed an alarm system under him/her, which required direct physical contact with the Resident. The two staff completed the transfer and were observed exiting the dayroom, neither of the two staff were observed performing hand hygiene. - On 2/16/22 at 10:49 A.M., the surveyor observed two facility staff in Resident #52 's room. The door of the room was opened to reveal two staff wearing surgical masks (no face shields, no gowns, and no gloves) and performing direct physical care. One of the two facility staff was observed handling soiled linen and trash without PPE. During an interview on 02/16/22 at 01:38 P.M., the IP said after reviewing the guidance staff should be wearing eye protection, masks, and full PPE with high contact care. She said she had reached out to the state epidemiology department to discuss the outbreak but did not discuss the type of PPE the staff should be wearing during the outbreak. 2. On 2/18/22 at 10:54 A.M., the surveyor observed a facility staff member wearing a face shield, surgical mask, and gloves (no N95 and no gown), approach a resident seated in the hallway and perform a nasal swab. After performing the test, she removed her gloves and placed them in an open, clear plastic bag that was tied to the side of the cart. During an interview on 2/18/22 at 10:56 A.M., the facility staff member identified herself as working in medical records (MR). She said that she was conducting COVID-19 PCR (polymerase chain reaction) outbreak testing of all but two residents on Unit 2. On 2/18/22 at 10:58 A.M., the surveyor observed the MR staff push the COVID-19 testing supply cart down the hallway toward the elevator. At this time, Resident #11 was walking down the hallway toward her. Two Certified Nursing Assistant's held the resident's hands while the MR staff performed the nasal swab. The MR staff had neither a N95 mask nor a gown on. The two CNAs were not wearing N95 masks, gowns, or gloves while the test was being performed. After performing the test, she removed her gloves and placed them in an open, clear plastic bag that was tied to the side of the cart. During an interview on 2/18/22 at 11:45 A.M., Unit Manager #2 said she observed the MR staff member performing COVID-19 PCR tests on the unit wearing inappropriate PPE but did not intervene. She said that in addition to eye protection and gloves, staff should have worn a gown and an N95 mask while performing the testing.

Based on observation, staff interview, and medical record review, the facility failed to ensure that staff met professional standards of practice for eight Residents (#47, #26, #39, #51, #15, #49, #52, and #34), out of a total sample of 15 residents. Specifically, the facility failed: 1.) For Resident #47, to ensure a physician's order was obtained prior to using a catheter to obtain a urine sample; 2.) For Resident #26, to follow a physician's order to apply pressure relieving booties, and failed to obtain a physician's order prior to implementing an alternating pressure relieving mattress to the Resident's bed; 3.) For Resident #39, to follow physician's orders to apply pressure relieving booties; 4.) For Resident #51, to ensure a bed alarm was applied to the Resident's bed as ordered by the physician, and failed to ensure that documentation was accurate on the Treatment Administration Record (TAR); 5.) For Resident #15, to ensure a physician's order was obtained prior to sending him/her out to the hospital for evaluation; 6.) For Resident #49, to follow physician's orders for 15-minute safety checks of the Resident; 7.) For Resident #52, to: a.) ensure the staff followed a physician's order to apply the Resident's TED ([CONDITION(S)]-deterrent) stockings daily, (TED stocking help stop blood clots from developing); and b.) transcribe medications properly and administer the medications per the physician's orders; and 8.) For Resident #34, to provide continuous supervision during all meals, per the physician's order, and document accurately. Findings include: 1.) Resident #47 was admitted to the facility in April 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 1/21/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating the Resident had severe cognitive impairment. Further review of the MDS indicated the Resident is frequently incontinent of urine. Review of Resident #47's Nurse Progress Notes, dated 2/17/22, indicated a urine sample was obtained for a UA C&S (urinalysis, culture, and sensitivity) (a urine test to identify infection) via a catheter (a soft, thin tube used to pass urine from the body). Review of the February 2022 Physician's Orders indicated an order, dated 2/16/22, to obtain a urine for a UA C&S. There was no documented evidence there was a physician's order to obtain the urine using a catheter. During an interview on 2/22/22 at 1:40 P.M., Nurse #5 said a physician's order must be obtained prior to using a catheter to collect a urine sample from a resident. 2.) Resident #26 was admitted to the facility in October 2010 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS assessment, dated 12/22/21, indicated the Resident was at risk for the development of pressure ulcers. Review of Resident #26's February 2022 Physician's Orders indicated the following: -Heels: open Heel booties to both feet at all times, may remove for hygiene -Heelzup cushion- at all times when in bed to off-load [distribute the load to other areas which are not susceptible to pressure] the heels -Quilted plaid bootie to the left heel at all times On 2/16/22 at 11:34 A.M., the surveyor observed Resident #26 sitting in a Broda chair (positioning chair). He/she did not have booties on his/her heels. On 2/17/22 at 3:27 P.M., the surveyor observed Resident #26 lying in bed. The Resident's mattress was an alternating air mattress (a mattress designed to help prevent and aid in the prevention of pressure ulcers and comfort). The technology is based on the weight of the resident for optimal comfort and prevention. The surveyor observed the setting of the mattress to be at 125 pounds. On 2/22/22 at 10:20 A.M., the surveyor observed Resident #26 sitting up in his/her Broda chair. He/she did not have booties on his/her heels. On 2/22/22 at 2:00 P.M., the surveyor observed Resident #26 lying in bed. The alternating air mattress was set at 125 pounds. He/she did not have booties on to both heels and heels were not elevated on the Heelzup cushion. Further review of the medical record indicated there was no Physician's Order for the alternating air mattress. During an interview on 2/22/22 at 2:08 P.M., Nurse #5 said there must be a physician's order for the Resident to have an air mattress on their bed. Nurse #5 said the mattress is adjusted by weight. Nurse #5 said the Resident should have his/her booties on at all times and should have the Heelzup cushion while in bed. Further review of the medical record indicated the Resident's most recent weight, dated 2/9/22, was 180.6 pounds. Based on the Resident's weight, the setting of 125 pounds for the alternating air mattress was incorrect. During an interview on 2/22/22 at 3:27 P.M., the Assistant Director of Nurses (ADON) said the Resident should have his/her booties on at all times and the Heelzup cushion while in bed. The ADON said there should be a physician's order for the air mattress and that it should indicate the setting of the mattress. 3.) Resident #39 was admitted to the facility in April 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent MDS assessment, dated 1/5/22, indicated the Resident had a BIMS of 14 out of 15 indicating the Resident was cognitively intact. Further review of the MDS indicated the Resident was at risk for the development of pressure ulcers. Review of the February 2022 Physician's Orders indicated the following: -Booties- apply to bilateral feet when in bed On 2/16/22 at 11:57 A.M., the surveyor observed Resident #39 lying in bed. He/she did not have booties on. On 2/22/22 at 10:55 A.M., the surveyor observed Resident #39 lying in bed. He/she did not have booties on. On 2/23/22 at 9:40 A.M. the surveyor observed Resident #39 lying in bed. He/she did not have booties on. During an interview on 2/23/22 at 9:40 A.M., Resident #39 said staff never put the booties on him/her. During an interview on 2/23/22 at 11:34 A.M., Certified Nursing Assistant #4 said the Resident has not had booties for a while. During an interview on 2/23/22 at 11:40 A.M., Nurse #8 said that if a resident had a physician's order for booties, they would be applied per the order. She said if the booties were not available or were not put on the Resident, the nurse would document on the Treatment Administration Record (TAR) that the booties were not applied and why the booties were not applied. Nurse #8 said Resident #39 does not like to wear the booties. Review of the medical record did not indicate any documented evidence that the Resident was refusing to wear the booties. Review of the February 2022 TAR indicated staff were documenting the application of booties daily between 2/1/22-2/21/22. 4. Resident #51 was admitted to the facility in January 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS assessment, dated 1/12/22, indicated Resident #51 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, and had one fall since the prior assessment. Review of the medical record indicated the following Physician's Order, initiated 11/1/21: - bed alarm at all times when in bed. On 2/16/22 at 10:27 A.M., the surveyor observed Resident #51 lying in bed. A dark gray wire was observed sticking out from underneath the blanket, dangling down the edge of the bed, and was lying on the floor. The wire had a plastic connector on the end and was not connected to anything. On 2/17/22 at 8:31 A.M. and 1:38 P.M., the surveyor observed Resident #51 lying in bed. A gray cord was observed dangling onto the floor and not connected to anything. On 2/18/22 at 10:00 A.M., the surveyor observed Resident #51 lying in bed sleeping. A gray cord was observed dangling onto the floor and not connected to anything. On 2/18/22 at 11:00 A.M., the surveyor observed an alarm box on the edge of Resident #51's bed with the dark gray cord connected to it. None of the three indicator lights were illuminated to indicate that the unit had power. Review of February 2022 TAR indicated the bed alarm was in place as ordered by the physician on the dates and times of the Surveyor's observation of the device not in place. During an interview on 2/18/22 at 11:45 A.M., Unit Manager #1 said staff should not have documented that the bed alarm was in place and functioning when it was not. 5. Resident #15 was admitted to the facility in February 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a Nursing Progress Note, dated 2/19/22, indicated Resident #15 complained of a headache, feeling dizzy, left flank pain, and abdominal discomfort. The nurse contacted the physician who gave a verbal order to send the Resident to the hospital for evaluation. Further review of the medical record failed to indicate a written physician's order to send the Resident to the hospital was in the medical record. During an interview on 2/23/22 at 1:25 P.M., the surveyor and Nurse #2 reviewed the Resident's medical record. She said after speaking to the physician, she should have written a telephone order to send Resident #15 to the hospital for evaluation. 6. Resident #49 was admitted to the facility in May 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2022 Physician's Orders indicated the Resident was to be checked for safety every 15 minutes. On 2/16/22 at 10:20 A.M., the surveyor observed a Stop sign attached to the two door jams and a chair placed directly in front of Resident #49's room. The chair was attached to the guard rail with a gait belt, and there was a sign posted on the door stating, DO NOT REMOVE CHAIR IN FRONT OF DOOR (UNIT MANAGER). The door to the room was shut. On 2/16/22 at 10:20 A.M., the surveyor observed Resident #49 asleep in an oversized chair and the room was dark and the lights were not on. The Resident's breakfast was in front of him/her, his/her catheter continuous drainage (CD) bag was attached to tube that was inserted in the resident and then stretched across the floor and attached to a walker. Resident #49's oxygen tubing was draped along the floor and between the oxygen concentrator, the bed, and the chair. The Resident's bed was covered with personal items, including snacks, hygiene products, and paper. On 2/16/22, 2/17/22, 2/18/22, 2/22/22 and 2/23/22 at various times of the days, multiple surveyors observed Resident #49. Resident #49's door was shut during all observations and the chair blocking entrance to the room and the posting remained in place. Surveyors made frequent observations of the Resident and the condition of his/her room. At no time did the surveyors observe staff check Resident #49 every 15 minutes for safety. Review of Resident #49's medical record failed to indicate the staff were conducting the physician ordered safety checks. During an interview on 2/22/22 at 2:50 P.M., Unit Manager #1 said she wasn't sure why the interventions for safety were not documented. She said the treatment should have been included on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 2/23/22 at 1:00 P.M., Nurse #7 said she was unaware the physician had ordered 15-minute safety checks for Resident #49. 7. Resident #52 was admitted to the facility in January 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a.) Review of the Physician's Orders indicated TED stockings were to be applied every morning and removed before bed. On 2/16/22 at 1:30 P.M., the surveyor observed Resident #52 in his/her room and was up and dressed and not wearing the TED stockings. On 2/17/22 at 12:50 P.M., the surveyor observed Resident #52 in his/her room and was up and dressed and not wearing the TED stockings. On 2/22/22 at 2:20 P.M., the surveyor observed Resident #52 in his/her room, was up, dressed, visiting with a family member, and not wearing the TED stockings. On 2/23/22 at 1:00 P.M., the surveyor observed Resident #52 in his/her room and not wearing the TED stockings. Review of the MAR for January 2022 and February 2022 indicated the nursing staff signed that the TED stockings had been applied and removed daily, including 2/16/22, 2/17/22, 2/22/22, and 2/23/22. During an interview on 2/23/22 at 1:00 P.M., Nurse #7 said the nursing staff are responsible for applying the Resident's TED stockings daily. Nurse #7 said this is confirmed by their signatures on the MAR. The surveyor shared the observations of Resident #52 not wearing the TED stockings. b.) Record review of the Physician's Orders for Resident #52 and of the November 2021 through February 2022 MARs indicated the following: - From 11/1/21 - 1/21/22, the blood pressure medication, [MEDICATION(S)] 25 milligrams (mg), was to be administered twice a day, and to hold if the systolic blood pressure (SBP) was less than 100 or the apical pulse and/or heart rate (AP/HR) was less than 60. Review of the November 2021, December 2021, and January (1- 21) 2022 MARs indicated the medication was administered 11 times when the AP/HR and the SBP were outside of the vital sign parameters, and the medication should not have been administered. On two occasions, the medication was held when the AP/HR and the SBP were within the vital sign parameters and the medication should have been administered. On 1/21/22, the Nurse Practitioner wrote a new order and decreased the [MEDICATION(S)] from 25 mg to 12.5 mg, twice a day, and to hold if the systolic blood pressure (SBP) was less than 100 or the apical pulse and/or heart rate (AP/HR) was less than 60. Review of the January (21-31) and February (1-22) 2022 MARs indicated the medication was administered one time, when the AP/HR and the SBP were outside of the vital sign parameters. However, on 65 occasions, and prior to the administration of the medication, the Resident's AP/HR was not obtained, and the medication was administered without the vital signs. The order to obtain the AP/HR prior to administration of the medication had been transcribed into the order but not onto the MAR. During an interview on 2/23/22 at 1:30 P.M., the Assistant Director of Nurses said the medications should have been administered as ordered by the physician. Further review of the Physician's Orders for Resident #52 included the following: -[MEDICATION(S)] (an antihistamine that is used to treat or prevent dizziness and or used to treat symptoms of [CONDITION(S)], dizziness or spinning sensation) 12.5 mg, three times per day as needed/ PRN, start date 11/7/21 On 12/15/21, the NP's progress note indicated the Physical Therapist reported Resident #52 complained of [CONDITION(S)] and fatigue when ambulating in the hallway. The NP suggested the staff administer the PRN [MEDICATION(S)] prior to Resident #52 receiving physical therapy. Review of the Nurse's Note, dated 12/15/21, indicated the NP had assessed the Resident's dizziness when receiving physical therapy. The nurse's note indicated the medication [MEDICATION(S)] was to be administered prior to physical therapy. The staff transcribed the order as follows, [MEDICATION(S)] 12.5 mg daily, administer 20 minutes prior to therapy. The order was not transcribed to include to administer the PRN medication dose. Record review indicated Resident #52's physical therapy was discontinued (stopped) on 12/24/21. Review of the December 2021 (16-31) MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the January 2022 and February (1-16) 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/7/22, the NP ordered [MEDICATION(S)] 12.5 mg daily. Review of the NP's progress note, dated 1/12/22, indicated she scheduled the medication because staff were not administering the PRN dose of the medication and the Resident's dizziness was affecting his/her overall condition. Review of the January (7-31) and February (1-16) 2022 MARs indicated the medication was administered a total of 80 times. During an interview on 2/23/22 at 11:00 A.M., the ADON and surveyor reviewed Resident #52's medical record. She said that she was not aware of the medication being administered after his/her physical therapy had ended. She said that staff should have clarified the order with the NP and administered the PRN as directed by the NP. 8. Resident #34 was admitted to the facility in June 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the recent Minimum Data Set (MDS) assessment, dated 12/20/21, indicated Resident #34 scored a 14 out of 15 on his/her Brief Interview for Mental Status (BIMS), indicating he/she was cognitively intact; was visually impaired and required extensive assistance in most of his/her activities of daily living. During an interview on 2/16/22 at 10:00 A.M., Resident #34 said the staff brought his/her meals to the room and left it on the tray table, and then the staff would return later and take the tray away. Review of the current Physician's orders specified the Resident was to be provided supervision with all meals. Review of Resident #34's aspiration and choking care plan, dated 6/30/21 and revised on 12/29/21, indicated the Resident required continuous supervision for all meals. On 2/17/22 at 8:40 A.M. and at 12:41 P.M., and on 2/23/22 at 12:40 P.M., the surveyor observed Resident #34 alone in his/her room and eating his/her meals. The surveyor did not observe the facility staff provide continuous supervision per the physician's order. Review of Resident #34's Medication Administration Records for January 2022 and February 2022 indicated the nursing staff documented three times a day that the Resident was provided continuous supervision with his/her three meals. During an interview on 2/23/22 at 1:00 P.M., Nurse #7 said Resident #34 was not and has not been provided continuous supervision during meals.

Based on policy review, observation, record review, and interview, the facility failed to ensure that respiratory equipment was managed in accordance with professional standards of practice for four Residents (#7, #33, #47, and #49), out of a total sample of 15 residents. Findings include: Review of the facility's policy titled Use of Oxygen Concentrators, last reviewed 10/20/21, included but was not limited to: -oxygen cannula [small, flexible tube that contains two open prongs intended to sit just inside your nostrils to deliver oxygen] or mask will be changed weekly and as needed -oxygen tubing will be dated and labeled 1. Resident #7 was admitted to the facility in November 2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record indicated the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] solution for nebulization, 2.5 milligrams/ 3 milliliters inhalation four times a day (2/1/21) -Change nebulizer tubing every week on 11:00 P.M.-7:00 A.M. shift. *Must label tubing with the date (10/12/21) -Oxygen at 2 liters per minute continuously via nasal cannula (11/2/21) -Change and date new oxygen tubing weekly (12/5/21) On 2/16/22 at 9:54 A.M., the surveyor observed Resident #7 sleeping in a reclined Broda chair (positioning chair) in his/her room. The oxygen tubing was noted to be connected to the concentrator, with a nasal cannula in place in the Resident's nostrils. The concentrator was on and set to a flow rate of 2 liters/minute. The surveyor inspected the oxygen tubing and noted that there was no label fastened to it to ascertain when it was last changed. On 2/17/22 at 8:27 A.M., the surveyor observed Resident #7 in his/her room seated in a Broda chair. The oxygen tubing was noted to be connected to the concentrator, with a nasal cannula in place. There was no label fastened to it to ascertain when it was last changed. On 2/18/22 at 11:56 A.M., the surveyor observed Resident #7 in the elevator. The oxygen tubing was noted to be connected to a portable oxygen tank, with a nasal cannula in place. The surveyor inspected the oxygen tubing and noted that there was no label fastened to it to ascertain when it was last changed. 2. Resident #33 was admitted to the facility in June 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record indicated the following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Oxygen at 2 liters/minute continuously via nasal cannula (9/24/21) -Change and date new oxygen tubing weekly on 11:00 P.M.-7:00 A.M. shift (12/5/21) On 2/16/22 at 10:08 A.M., the surveyor observed Resident #33 lying in bed sleeping. The oxygen tubing was noted to be connected to the concentrator, with a nasal cannula in the Resident's nostrils. The concentrator was on and set to a flow rate of 2 liters/minute. The surveyor inspected the oxygen tubing and noted that there was no label fastened to it to ascertain when it was last changed. On 2/17/22 at 10:22 A.M., the surveyor observed Resident #33 seated in a Broda chair in his/her room. The oxygen tubing was noted to be connected to the concentrator, with a nasal cannula in place. There was no label fastened to it to ascertain when it was last changed. On 2/18/22 at 9:59 A.M., the surveyor observed Resident #33 lying in bed awake. The oxygen tubing was noted to be connected to the concentrator, with a nasal cannula in place. There was no label fastened to it to ascertain when it was last changed. On 2/22/22 at 11:38 A.M., the surveyor and Assistant Director of Nursing (ADON) inspected Residents #7 and #33's oxygen tubing. The ADON said that she could not easily determine when the tubing was last changed, and staff should date and label the tubing. 3.) Resident #47 was admitted to the facility in April 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the most recent Minimum Data Set (MDS) assessment, dated 1/21/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating the Resident had severe cognitive impairment. On 2/16/22 at 12:00 P.M., the surveyor observed Resident #47 lying in bed receiving oxygen. The oxygen tubing was noted to be connected to the concentrator, with a nasal cannula in the Resident's nostrils. The concentrator was on and set at 3 liters/minute. The surveyor inspected the tubing and observed that the tubing was not dated or labeled. On 2/22/22 at 2:21 P.M., the surveyor observed Resident #47 lying in bed receiving oxygen. The oxygen tubing was noted to be connected to the concentrator, with a nasal cannula in the Resident's nostrils. The concentrator was on and set at 3 liters/minute. The surveyor inspected the tubing and observed that the tubing was not dated or labeled. Review of the February 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - change oxygen tubing and filter weekly on Tuesday 11:00 P.M.-7:00 A.M. - oxygen at 3 liters/minute via n/c (nasal cannula) continuously Review of the February 2022 Treatment Administration Record failed to indicate any documented evidence that the oxygen tubing was changed. Review of the February 2022 Nursing Progress Notes failed to indicate any documented evidence that the oxygen tubing was changed. During an interview on 2/22/22 at 1:45 P.M., Nurse #5 said that oxygen tubing is changed weekly. She said the tubing should be dated and labeled when changed. 4. Resident #49 was admitted to the facility in May 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 11/20/21, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the Resident was cognitively intact. Review of the current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - nasal cannula tubing, long green tubing, and filter, change and date new oxygen tubing weekly on every Tuesday night - oxygen at 2.5 liters/minute to maintain oxygen saturation greater than 90% every shift On 2/16/22 at 10:20 A.M., the surveyor observed Resident #49 sitting up in his/her oversized chair with oxygen on. The oxygen tubing was noted to be connected to the concentrator with a nasal cannula in place in the Resident's nostrils. The concentrator was turned on and was set to a flow rate of 2.5 liters/minute. A long, green tubing was attached to the nasal cannula and was draped on the floor from the concentrator to the Resident. The Resident's continuous draining catheter bag was on the floor next to the oxygen tubing. The surveyor inspected the oxygen tubing and did not observe it to have any labeled documentation of date and time tubing was last changed. On 2/17/22 at 9:13 A.M. and 12:35 P.M., the surveyor observed Resident #49 sitting up in his/her oversized chair in his/her room with oxygen on. The surveyor inspected the oxygen tubing and did not observe any labeled documentation of when the tubing was last changed. The oxygen concentrator was set at 2.5 liters/minute. On 2/22/22 at 2:15 P.M., the surveyor observed Resident #49 sitting in his/her chair with the oxygen on. The surveyor inspected the oxygen tubing and did not observe any labeled documentation of when the tubing was last changed. During an interview on 2/23/22 at 1:45 P.M., the Assistant Director of Nurses said staff were to label the oxygen tubing when they change it.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who had a history of Dementia and required extensive assistance of two people with activities of daily living (ADLs), the Facility failed to ensure his/her safety was maintained to prevent an incident resulting in an injury. On 10/04/21 nursing staff did not use the appropriate sling size per manufacturer's recommendation for Resident #1's weight during a mechanical lift transfer. Resident #1 fell through the sling on to the floor and sustained fracture(s) to his/her lower legs. Findings include: The Facility's Policy titled, Resident Transfer and Repositioning, undated, indicated all resident care will be provided in a safe, appropriate and timely manner in accordance with the president's plan of care. The Policy indicated administration will ensure that mechanical lifting devices and other equipment and aides are available to staff. The Policy indicated nursing staff will ensure that mechanical lifting devices and other equipment and aides are accessible to staff and stored conveniently and safely. A review of the Facility's Fall Prevention Program, dated 10/2020, indicated its purpose is to prevent resident falls through systematic and regular identification of risk factors for each resident. Resident #1 was admitted to the Facility in February 2017, diagnoses included Alzheimer's disease and generalized muscle weakness. Based on review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], indicated he/she was totally dependent on two people with transfers. Review of Resident #1's Plan of Care related to Activities of Daily Living (ADL), dated 07/07/21, indicated Resident #1 was dependent on two people for assistance with the following; bathing, grooming, dressing, transfers, toileting, bed mobility and positioning. Review of Resident #1's Clinical Record, dated 10/04/21, indicated Resident #1's weight was 102 pounds. Review of the report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 10/08/21, indicated Resident #1 was being transferred with a mechanical (hoyer) lift from bed into his/her wheelchair, and that Resident #1 slipped from the mechanical lift sling and landed upright onto the floor under the mechanical lift during the transfer. The Report indicated that Resident #1 sustained injuries to both right and left lower extremities. Review of the Sling Manufacturers (ARJO's) Sling Color and Size Guide, undated, indicated there was a designation of colors to sling sizes as a guide to users based on the patient's weight. The color guide indicated the following: -Small (S) sling size; the color is Red for the recommended weight range 77 pounds to 132 pounds. -Medium (M) sling size: the color is Yellow for the recommended weight range 121 to 165 pounds. -Large (L) sling size: the color is Green for the recommended weight range 154 to 264 pounds. -Extra Large (XL) sling size: the color is Blue for the recommended weight range 308 to 440 pounds. Arjo's (Sling Manufacturer's) Guide recommendations, staff members were to use the small (S) red sling when transferring Resident #1 with the mechanical lift. A review of the Facility's Resident Incident Report, dated 10/04/21, indicated Resident #1 slid off the sling on to the floor, hitting his/her buttocks on the floor. The Report indicated that Resident #1 sustained multiple bruises to his/her right arm, right and left lower legs and a skin tear to right elbow. Review of Resident #1's Radiology Report, dated 10/04/21, indicated Resident #1 had acute fractures to his/her left leg. Review of Resident #1's Hospital Discharge Summary, dated 10/08/21, indicated Resident was recently (four days ago) treated at the Hospital Emergency Department for left leg fracture after a fall. The Summary indicated that Resident #1 returned on 10/08/21 after complaints of right leg pain. The Summary indicated Resident #1 sustained fractures to his/her right leg and ankle. Review of Certified Nurse Aide (CNA) #1's Written Witness Statement, dated 10/04/21, indicated that CNA #1 was assisting CNA #2 with transferring Resident #1 out of bed into his/her wheelchair, while in a seated position he/she slid through the hole in mechanical lift sling and fell on to the floor. During an interview on 11/04/21 at 2:40 P.M., Certified Nurse Aide (CNA) #1 said on 10/04/21, she was assigned to care for Resident #1 who required a mechanical lift transfer from bed into his/her wheelchair. CNA #1 said with Resident #1 in bed, she placed the mechanical lift sling underneath him/her. CNA #1 said she called for CNA #2 to help transfer Resident #1 from bed in to his/her wheelchair. CNA #1 said while she manipulated the mechanical lift controller to lift Resident #1 from the bed, CNA #2 positioned the wheelchair to receive him/her. CNA #1 said when Resident #1 was lifted and in motion towards the wheelchair, Resident #1 slid through the sling and fell to the floor. CNA #1 said Resident #1's legs were crossed over when he/she landed on the floor. CNA#1 said she called for Nurse #1 who came in and assessed Resident #1. CNA #1 said she observed Resident #1 bleeding from the elbow. CNA #1 said the sling she used (based on the Facility investigation CNA #1 used a large greed sling) to transfer Resident #1 was the same one assigned to him/her and that it was kept in Resident #1's room. CNA #1 said she did not use the red (small) colored sling as recommended for Resident #1's weight. The ARJO's Sling Color and Size Guide, indicated the Large (L) sling size: the color is Green for the recommended weight range 154 to 264 pounds. During an interview on 11/04/21 at 11:35 A.M., Certified Nurse Aide (CNA) #2 said on 10/04/21, she and CNA #1 used the mechanical lift to transfer Resident #1 from bed in to wheelchair and CNA #2 said CNA #1 had already placed the sling underneath Resident #1 before she came into the room. CNA #2 said CNA #1 she was in charge of the controller of the lift while she directed the wheelchair. CNA #2 said she did not pay attention to the placement of the sling prior to the transfer. CNA #2 said Resident #1 slid and fell through the mechanical lift sling while the sling straps were still hanging on the mechanical lift machine. CNA #2 said the Director of Nurses came to the room and took the sling away and said that a smaller sling would be made available for staff members to use when transferring Resident #1. CNA #2 said it was then that she realized that CNA #1 had placed a large (green colored) sling underneath Resident #1 prior to the transfer. During an interview on 11/04/21 at 12:45 P.M., Nurse #1 said she was administering medications to another resident when Certified Nurse Aide (CNA) #1 came to her and reported that Resident #1 had fallen. Nurse #1 said she found Resident #1 with his/her legs expended on the floor, and that there was positive range of motion on all extremities without any signs and symptoms of pain. Nurse #1 said when Resident #1 was later transferred to bed, she observed a bruise on his/her left leg, Nurse #2 said called the Physician and obtained an order for an x-ray of the leg. Nurse #1 said the results indicated Resident #1 sustained a fracture to his/her left leg. Nurse #1 said Resident #1 was transferred to the hospital emergency department for further evaluation and returned to the Facility. Nurse #1 said a few days later, he/she was transferred to the hospital when Resident #1 presented with signs and symptoms of pain and injury to the right leg. Review of Resident #1's Progress Note, dated 10/04/21, indicated that at 8:30 A.M., Certified Nurse Aide (CNA) #1 reported to Nurse #1 that Resident #1 was on the floor on his/her buttocks. The Note indicated Nurse #1 found Resident #1 under the mechanical lift. The Note indicated Nurse #1 assessed Resident #1 with a skin tear measuring 0.5 by 0.5 centimeters (cm) on his/her left elbow. The Note indicated she later found bruising to Resident #1's left outer ankle, which was swollen and painful to touch. The Note indicated Nurse #1 assessed purple bruise to right foot and right chin. The Note indicated Nurse #1 called the Physician for orders to have the left leg and ankle x-rayed. During an interview on 11/04/21 at 1:50 P.M., the Director of Nurses (DON) said she was informed that Resident #1 fell from a mechanical lift during transfer. The DON said she was responsible for the investigation and that she did not find any obstacles or barriers that might have led to the incident. The DON said Resident #1 was not combative, that two Certified Nurse Aides (CNAs) did the transfer and that there was no wear and or tear to the mechanical lift sling. The DON said the large green colored sling was used to transfer Resident #1, indicating a large green sling was used instead of the small red one as recommended for Resident #1's weight. During an interview on 11/23/21 at 11:00 A.M., the Administrator said she later learned after the fall incident involving Resident #1 that a large size (green colored) sling was used to transfer Resident #1 on 10/04/21 when he/she fell during the mechanical lift transfer.

Based on records reviewed and interviews, the Facility failed for one of three sampled residents (Resident #1), to ensure staff implemented the plan of care. Resident #1 required a mechanical lift and two assists for all transfers. On 5/4/16, Certified Nurse Aide (CNA) #1 transferred Resident #1 with the mechanical lift from the bed to the Tilt N Space chair (chair which allows a change in position for residents who cannot self maintain position and/or balance for prolonged periods of time), without assistance of another staff person. Following the transfer, CNA #1 wheeled Resident #1 into the hallway and reported to Nurse #1 that she observed a laceration on the top of Resident #1's head. Findings include: An annual Minimum Data Set (MDS) assessment, dated 4/1/16, indicated Resident #1's [DIAGNOSES REDACTED]. The Care Plan for Inability to stand, initiated 3/22/16, indicated Resident #1 required a mechanical lift with two assists for all transfers The CNA Care Plan Card, not dated, utilized by the CNA's providing care, indicated Resident #1 required a mechanical lift with assistance of two staff members for all transfers. Review of the Facility policy, Resident Transfer & Repositioning Policy, dated as revised in July 2015, indicated transfer of a resident utilizing a mechanical lifting device requires 2 staff members. Resident #1 was unable to be interviewed due to his/her impaired cognition. The Resident Incident Report, dated 5/4/16, indicated at 6:45 A.M., as CNA #1 was giving Resident #1 juice, she observed a long cut on the top of Resident #1's head which appeared to be bleeding and reported the incident. The report indicated Resident #1 was assessed with [REDACTED]. The incident report indicated Resident #1 was transferred to the emergency room for treatment of [REDACTED].#1 admitted she transferred Resident #1 with the mechanical lift from the bed to the Tilt N Space chair without assistance of another staff person, which was not consistent with Resident #1's plan of care. Surveyor #1 attempted to interview CNA #1, however CNA #1 did not respond to phone calls or letter, and was unable to be interviewed. Surveyor #1 interviewed the Director of Nurses at 8:15 A.M., and throughout the day on 7/21/16. The Director of Nurses said during the Facility investigation, and upon further questioning, CNA #1 told her she never witnessed Resident #2 hit Resident #1. The Director of Nurses said no additional witness were identified to collaborate CNA #1's recall of the alleged incident, and the Facility was unable to conclude that Resident #1's [MEDICAL CONDITION] was caused by Resident #2's actions. The Director of Nurses said as part of the Facility investigation, CNA #1 was interviewed a second time. The Director of Nurses said CNA #1 told her that she had transferred Resident #1 with the mechanical lift, alone, without the assistance of another staff person. The Director of Nurses said it was the expectation that all care providers review care cards and plans of care for appropriate interventions, and that all care be provided per resident's plan of care. Review of the Facility investigation dated 5/4/16, included a statement dated 5/4/16 and signed by CNA #1. The statement indicated due to the nature of the injury to Resident #1, it seems to have occurred with the hoyer lift. I was unfortunately using it alone that morning. I was unaware that she was hurt or it would have been reported. I hadn't notice the cut until I was giving her some juice. On 7/21/16, the Facility was found to be in past noncompliance. In response to the incident the Facility took the following corrective action: A) CNA #1 was no longer employed at the Facility as of 5/17/16. B) A Facility wide audit was completed on 5/4/16, including CNA #1's resident assignment to assure identified residents who required two assists for transfers were provided care according to individual care plans. C) A Facility wide mandatory in-service program was initiated on 5/9/16 and completed on 5/19/16 regarding failure to follow the plan of care, safe transfer and repositioning, safe resident handling, use of Tilt N Space chairs, and abuse and neglect. As part of the mandatory in-service, Physical and Occupational therapist and a representative from the company which supplies the mechanical lifts to the Facility, presented an in-service which was specific to the use of Tilt N Space chairs. A video recording was made of the in-service which was to be used for orientation of new employees and future in-services and education as indicated. D) On 5/5/16, the Facility initiated unannounced mechanical lift audits for all three shifts. The unannounced audit was to be two to three times weekly for two weeks, then weekly for two months and then monthly. E) The Director of Nurses was responsible to implement and monitor the on-going audits and present the findings to the Quality Assurance Performance Improvement Committee. F) The Quality Assurance Performance Improvement Committee will continue to review findings with additional measures to be implemented as needed.

Based on records review and interviews, the Facility failed for one of three sampled residents (Resident #1), to ensure that Resident #1 was transferred with an assist of two staff persons per Plan of Care which resulted in an avoidable injury. On 5/4/16, Certified Nurse Aide (CNA) #1 transferred Resident #1 with the mechanical lift from the bed to the Tilt N Space chair (chair which allows a change in position for residents who cannot self maintain position and/or balance for prolonged periods of time), without assistance of another staff person. Following the transfer, CNA #1 wheeled Resident #1 into the hallway and reported to Nurse #1 that she observed a laceration on the top of Resident #1's head. Findings include: An annual Minimum Data Set (MDS) assessment, dated 4/1/16, indicated Resident #1's [DIAGNOSES REDACTED]. The Care Plan for Inability to Stand, initiated 3/22/16, indicated Resident #1 required a mechanical lift with two assists for all transfers. The CNA Care Plan Card, utilized by the CNA's providing care, indicated Resident #1 required a mechanical lift with assistance of two staff members for all transfers. Review of the Facility policy, Resident Transfer & Repositioning Policy, indicated transfer of a resident utilizing a mechanical lifting device requires 2 staff members. Resident #1 was unable to be interviewed due to his/her impaired cognition. The Resident Incident Report, dated 5/4/16, indicated at 6:45 A.M., as CNA #1 was giving Resident #1 juice, she observed a long cut on the top of Resident #1's head which appeared to be bleeding. The incident report indicated Resident #1 was assessed with [REDACTED]. The incident report indicated Resident #1 was transferred to the emergency room for treatment of [REDACTED].#1 admitted she transferred Resident #1 with the mechanical lift from the bed to the Tilt N Space chair without assistance of another staff person, which was not consistent with Resident #1's plan of care. Surveyor #1 attempted to interview CNA #1, however CNA #1 did not respond to phone calls or letter, and was unable to be interviewed. Review of the Facility investigation dated 5/4/16, included CNA #1's Witness Statement, dated 5/4/16 at 6:35 A.M., and signed by CNA #1. The statement indicated CNA #1 found Resident #2 yelling as he/she stood near Resident #1. The statement indicated CNA #1 redirected Resident #2 back to his/her room. The statement indicated as CNA #1 returned with juice for Resident #1, she found Resident #2 again, standing near Resident #1 and Resident #2 was yelling out. The statement indicated CNA #1 redirected Resident #1 to his/her room and returned to Resident #1 to provide juice to him/her. The statement indicated as CNA #1 provided juice to Resident #1, she observed a long cut on Resident #1 that looked as though it was starting to bleed. The statement indicated CNA #1 requested help from another CNA. Surveyor #1 interviewed the Director of Nurses at 8:15 A.M., and throughout the day on 7/21/16. The Director of Nurses said during the Facility investigation, and upon further questioning, CNA #1 told her she never witnessed Resident #2 hit Resident #1. The Director of Nurses said no additional witness were identified to collaborate CNA #1's recall of the alleged incident, and the Facility was unable to conclude that Resident #1's head laceration was caused by Resident #1's actions. The Director of Nurses said as part of the Facility investigation, CNA #1 was interviewed again. The Director of Nurses said CNA #1 told her that she had transferred Resident #1 with the mechanical lift, alone, without the assistance of another staff person. The Director of Nurses said it was the expectation that all care providers review care cards and plans of care for appropriate interventions, and that all care be provided per resident's plan of care. Review of the Service Call Report, dated 5/6/16, indicated a service call was completed for the mechanical lift used by CNA #1 for transfer of Resident #1 on 5/4/16. The report indicated the mechanical lift was free of mechanical issues. Review of Resident #1's Emergency Department Discharge Summary, dated 5/4/16, indicated Resident #1 was assessed to have a laceration to the scalp, which required two staples to close the laceration. On 7/21/16, the Facility was found to be in past noncompliance. In response to the incident the Facility took the following corrective action: A) CNA #1 was no longer employed at the Facility as of 5/17/16. B) A Facility wide audit was completed on 5/4/16, including CNA #1's resident assignment to assure identified residents who required two assists for transfers were provided care according to individual care plans. C) A Facility wide mandatory in-service program was initiated on 5/9/16 and completed on 5/19/16 regarding failure to follow the plan of care, safe transfer and repositioning, safe resident handling, use of Tilt N Space chairs, and abuse and neglect. As part of the mandatory in-service, Physical and Occupational therapist and a representative from the company which supplies the mechanical lifts to the Facility, presented an in-service which was specific to the use of Tilt N Space chairs. A video recording was made of the in-service which was to be used for orientation of new employees and future in-services and education as indicated. D) On 5/5/16, the Facility initiated unannounced mechanical lift audits for all three shifts. The unannounced audit was to be two to three times weekly for two weeks, then weekly for two months and then monthly. E) The Director of Nurses was responsible to implement and monitor the on-going audits and present the findings to the Quality Assurance Performance Improvement Committee. F) The Quality Assurance Performance Improvement Committee will continue to review findings with additional measures to be implemented as needed.

Based on record review, observation and interview with staff, the facility failed to provide appropriate and adequate care and services to meet the needs of 2 Residents (#4 and 15) in a total sample of 20 residents identified with behavior problems, cognitive loss/dementia and psychosocial difficulties. Findings include: According to interview on 8/13/15 at 9:30 A.M., the Staff Development Coordinator said the facility used the Alzheimer's Association training program for The Basics for Best Care as the facility's policy for dementia care. Per review of this policy for dementia care, the facility promoted that a person's daily experience should reflect as much as possible that person's preferred individual lifestyle, while enabling a sense of usefulness, pleasure and success. The policy also stressed that every behavior was a communication about the individual's needs or concerns, and identified that a number of potentially correctable medical conditions, drug side effects and environmental influences could be contributing factors. The policy stated that recognizing symptoms, making a careful assessment and identifying possible causes would lead to proper treatment and intervention, and significantly reduce or stabilize symptoms. According to the Staff Development Coordinator, all facility staff had been trained in this program for dementia care and was part of their expected job performance. This information was confirmed during interview with the Administrator and Director of Nurses on 8/18/15 at 2:45 P.M. 1. For Resident #4, the facility failed to develop an individualized behavioral treatment plan with approaches for identified behaviors and only offered the Resident generalized interventions which did not address the Resident's behaviors and multiple psychoactive medications. The Resident's symptoms continued over a 10 month period, despite the concurrent use of multiple medications that included antipsychotics, antidepressants, anti-anxiety drugs, anti-Alzheimer's drugs and anti-convulsants. Resident #4 was admitted to the facility in 9/2014 after an acute hospitalization at a Behavioral unit for dementia with behavioral disturbance, manifested by increased confusion, anxiety and paranoia at home, according to the Social Worker's admission assessment. At the time of admission, the Resident received [MEDICATION NAME] 10 mg (milligrams) daily and [MEDICATION NAME] 100 mg at bedtime and 25 mg as needed (PRN), both antidepressants. Review of the care plan indicated that a problem of memory loss, confusion, anxiety, paranoia, depression, trouble sleeping and always trying to go home was initiated on 9/25/14. Although the care plan identified that the Resident use to be a seamstress and enjoyed gardening and flowers, the approaches were to let the Resident write things down, provide a routine, administer medications to help with depression, anxiety and sleep and attend religious services daily. The routine was not described and there was no specific intervention to address the Resident's attempts to go home nor the Residents past interests. Review of the facility's consultant Psychiatrist's note, date 10/28/14, the Psychiatrist described the Resident as anxious, restless, exit-seeking, with sleep and appetite decline (but without [MEDICAL CONDITION] or aggression). The assessment [DIAGNOSES REDACTED]. The Psychiatrist noted the Resident received [MEDICATION NAME] and [MEDICATION NAME] and recommended that the [MEDICATION NAME] be increased from 10 mg to 20 mg daily. There was no change documented in behaviors and no documentation of a failed non-pharmacological approach attempted. On 11/4/14, the Psychiatrist reviewed the Resident's status and wrote that the Resident was more anxious, had an increase in exit-seeking behaviors and wandered into other Residents' rooms. The recommendation was to consider [MEDICATION NAME] (an anti-anxiety medication) 10 mg twice daily. This was ordered on [DATE] with no documentation that any non-pharmacological approaches were attempted. On 11/10/14, the [MEDICATION NAME] was increased by the Nurse Practitioner with the addition of 25 mg in the morning and afternoon, and continue with 100 mg at bedtime and 25 mg twice daily PRN. The Psychiatrist reviewed the Resident again on 11/18/14, and noted that the Resident had a one to one sitter and continued efforts to elope. The Psychiatrist wrote that the Resident was delusional because of saying that he/she had to go to work or take care of the children. The Psychiatrist questioned that the [MEDICATION NAME] was increasing the Resident's agitation, and made a recommendation to discontinue that medication and start [MEDICATION NAME] (an antipsychotic medication) 0.25 mg twice daily. The physician ordered the [MEDICATION NAME] 025 mg daily. There was no identified [DIAGNOSES REDACTED]. Review of drug use guidelines as published by the Center for Medicare and Medicaid Services (CMS) for use in the elderly, as well as drug information provided by the federal Food and Drug Administration (FDA) indicating that [MEDICATION NAME] and other antipsychotics should not be used unless behavior symptoms present a danger to the Resident or others, and are identified as due to [MEDICAL CONDITION] or mania, or behavior interventions have been attempted and are included in the care plan. The care plan for this Resident as mentioned was developed on 9/25/14 and only includes the intervention of having the Resident write things down and provide a routine, without further specificity of approaches and direction to staff. Rather, when the care plan was updated on 11/19/14, the added approach was that the psychiatrist was trying new medication to lessen anxiety and attempts to leave and go home. The care plan also included that the Resident would have a one to one sitter, and a family meeting would b held. There were no approaches identified that provided any alternative behavior management interventions other than psychiatric medications, that might manage the Resident or divert the Resident's attention from the exhibited behavior. On 12/1/14, the Psychiatrist wrote that the Resident continued with exit-seeking behavior and could become labile when re-directed. The Psychiatrist noted the current medications, including the addition of [MEDICATION NAME] (anti-Alzheimer's) 5 mg at bedtime despite the continuation of the target behaviors being treated with antipsychotics for this Resident with dementia. The recommendation was to increase the [MEDICATION NAME] to 0.25 mg twice daily. There was no identified [DIAGNOSES REDACTED]. Record review revealed that on 12/29/14, the Resident eloped from the facility after returning from a family visit for the Christmas holiday (and was found knocking at the family home). The Resident was transferred to a acute geriatric-psychiatric unit and remained there until 1/6/15. The discharge summary noted that several medication changes were made. The Summary noted that with the medication changes, the Resident was less anxious, quite confused and wandered aimlessly in the hallway. Medications upon return include: * [MEDICATION NAME] - 10 mg per day for depression. * [MEDICATION NAME] (an anticonvulsant) - 375 mg at bedtime for mood stabilization. * [MEDICATION NAME] (anti-Alzheimer's medication) - 5 mg daily for dementia. * [MEDICATION NAME] (used for dementia) - 5 mg twice daily. * [MEDICATION NAME] - 0.25 mg daily at 2:00 P.M. and bedtime, and every 6 hours PRN for behavioral agitation and [MEDICAL CONDITION]. [MEDICATION NAME] 0.125 mg daily also added the day before discharge in addition to the twice daily ordered. * [MEDICATION NAME] (antidepressant) - 75 mg daily at bedtime for sleep and depression. The consultant Psychiatrist reviewed the Resident's status on 1/12/15. The Psychiatrist noted that the Resident remained on one to one monitoring for ongoing exit-seeking. Although there were no documented increase in behaviors or symptoms, the Psychiatrist recommended to change the [MEDICATION NAME] order to 0.5 mg twice daily and discontinue the PRN dose. (This recommendation was for twice the dose recommended by the hospital one week earlier with no justification for the increase). The Resident was seen by the Psychiatrist on the following dates and included the following changes: * 2/3/15 - the Resident was noted to be labile, aggressive and swinging out. A [DIAGNOSES REDACTED]. The [MEDICATION NAME] was discontinued and noted to be ineffective. [MEDICATION NAME] dose was increased and [MEDICATION NAME] (antianxiety) 5 mg every 8 hours PRN was added for agitation. The [DIAGNOSES REDACTED]. On 3/27/15, a secure care (electronic device triggering an alarm at exits) was added. Nurses' noted from 4/30/15 through 5/10/15 document continued wandering, intrusiveness, exit-seeking, aggressiveness and agitation. * 5/11/15 - The Resident is noted to continue to exit-seek with anxiety and restlessness. The recommendation was to increase the [MEDICATION NAME] to 1 mg every 8 hours PRN Although the Psychiatrist in a note, dated 5/18/15, documents that the Resident's behaviors have improved, Nurses' notes from 5/11/15 through 6/15/15 document that the Resident continued the behavior patterns previously documented. In addition, nurses' notes document episodes of urinating in various, random locations, wandering naked in the hallways and punching another Resident on 6/4/15 and punching a CNA on 6/14/15. There was no evidence that the psychoactive medication regime was effective in managing the Resident's behaviors and there remained no non-pharmaceutical interventions developed specific to the Resident's targeted behaviors. Review of the physician's orders [REDACTED]. - 5/27/25 - [MEDICATION NAME] was increased from 14 mg to 21 mg. - 6/3/15 - [MEDICATION NAME] discontinued - 6/8/15 - [MEDICATION NAME] discontinued. [MEDICATION NAME] decreased back to 14 mg for 7 days, then discontinued. - 6/8/15 - [MEDICATION NAME] (an antipsychotic) 2.5 mg twice daily started. The maximum recommended therapeutic dose of [MEDICATION NAME] for elderly persons is 5 mg daily, the initial dose ordered by the physician. On 6/8/15, the care plan for elopement was updated to include the discontinuation of the [MEDICATION NAME] and [MEDICATION NAME]. Per psychiatry in hope of decreasing the Resident's exit seeking. The plan still did not proved staff with non-pharmaceutical approaches for staff to use in working with the Resident for this exit-seeking behavior which was assessed as the Resident wanting to go home. The Psychiatrist reviewed the Resident's status again on 6/15/15, and noted the continued incidence of the Resident's exit-seeking to doors and elevator, did not have a one to one sitter but had 3 wanderguards (electric monitoring devices). The Psychiatrist wrote that the Resident was worse on the 3:00 P.M. to 11:00 P.M. shift, and after 8:00 P.M. the resident could be combative with re-direction, very intrusive with others and leaving dirty incontinent briefs in other resident rooms. The Psychiatrist noted that the Resident's sleep remained inconsistent with rare naps. Recommendations included to discontinue the [MEDICATION NAME] as it had failed and noted that [MEDICATION NAME] and [MEDICATION NAME] had failed. Recommendations included to add [MEDICATION NAME] (an antidepressant) 15 mg every 8 hours PRN for agitation and to increase the [MEDICATION NAME] from 250 mg three times daily to 375 mg twice daily and an addition 250 mg at noon. The Resident had been treated now 6 months with antipsychotic medication with no improvements and confirmed by the Psychiatrist that the medication regime had not been effective in treating the target behaviors. A dose reduction or drug holiday and trial of alternative non-pharmacological interventions were not considered. Rather, a continuation of alternative medications were the approach of choice without also use of non-pharmacological interventions. Review of the quarterly MDS (Minimum Data Set), with a reference date of 6/20/15, documented that the Resident was able to communicate without difficulty, had demonstrated memory loss and cognitive deficits, was depressed, displayed verbal behavioral symptoms and wandered frequently. The Resident was documented as independent with transfers and required only supervision for ambulation. The Resident was able to eat independently and used no restraints. The Psychiatrist continued reviews of the Resident and documented the following: - 6/22/15 - Remains aggressive and exit-seeking. [MEDICATION NAME] PRN not effective, discontinue. - Increase [MEDICATION NAME] 5 mg at noon and at bedtime. (This increased the daily dose to 10 mg, twice the maximum recommended therapeutic dose for elderly persons with dementia). - 6/28/15 - Documented to be very labile with constant exit-seeking, combative with re- direction, striking out. - Increase [MEDICATION NAME] to 375 mg three times daily. Discontinue [MEDICATION NAME] and start [MEDICATION NAME] (another antipsychotic) 8 mg three times daily. [MEDICATION NAME] has been issue a Black Box Warning by the FDA, stating that it is not approved for patients with dementia-related [MEDICAL CONDITION], and elderly patients with dementia-related [MEDICAL CONDITION] are at increased risk for death. The maximum recommended dose for elderly persons is 8 mg daily, and the initial dose recommended by the Psychiatrist was 24 mg daily, three times the recommended maximum. There was no documented justification for the excessive dose and no other non-pharmacological interventions attempted to manage the Resident's behavior. - 7/13/15 - Resident noted to be sedated. [MEDICATION NAME] decreased to 4 mg three times daily (this dose still exceeds the daily recommended dose for the elderly). A nurse's note, dated 7/19/15 at 10:00 P.M. documented the Resident as lethargic, shaky and unable to stand up on own without the assistance of 2 people. The Resident was noted to be unable to self feed and that evening medications were held. When a family member attempted to get the Resident out of a chair, the Resident fell and bumped his/her head and was sent to the emergency room for evaluation. The Resident was admitted to the hospital from 7/19/15 through 7/30/15 with [MEDICAL CONDITION], attributed to inappropriate antidiuretic hormone secretion and use of antipsychotic medications. The discharge summary indicates that the Resident did not present with any major psychotic symptoms and the [MEDICATION NAME] was reduced from 4 mg three times daily to 4 mg daily and to discontinue after two weeks. - 8/3/15 - The Psychiatrist documents the Resident as lethargic ant catatonic-like when awake, not self feeding and rarely verbal. Per the Health Care Proxy's request, [MEDICATION NAME] and [MEDICATION NAME] discontinued. During the initial tour of the unit on 8/11/15 at 8:20 A.M., Unit Manager #2 said that the Resident had a recent psychiatric unit admission for exit seeking and wandering. The Resident, who is described in the 6/20/15 MDS assessment as being independent in transfers and eating, with no restraint usage and requiring supervision for ambulation was observed on 8/11/15. The Resident was observed in a wheelchair, with a seatbelt in place with his/her head bent down towards his/her chest. Additional observations included: - 8/13/15 at 12:12 P.M. - A family member was feeding the Resident. The Resident was quiet and withdrawn. His/her eyes remained closed while being fed. - 8/14/15 at 9:15 A.M. - Resident in the wheelchair with the seatbelt in place in the back dining room of the second floor. Resident #4 was in a slouched position with his/her head down, eyes closed and quiet with no restless movement or agitated behavior. - At 11:20 A.M., the Resident was in the front dining room of the second floor observed to be seated in a slouched position, with his/her head down and eyes closed. The seatbelt remained in place. - 8/19/15 at 8:05 A.M. - Resident was seated at a table with three other residents and a CNA. The Resident was observed to be nonverbal with his/her head bent forward. The Resident was staring at the food on the plate in front of him/her but was not eating. The CNA was observed to feed both Resident #4 and another Resident seated at the table. The Resident remained nonverbal and opened his/her mouth for spoonfuls of food. - 8/19/15 at 12:05 P.M. - Resident being fed with eyes closed. The Resident did not speak even in response to comments from the CNA. Review of the care plan revealed no additional updates or revisions. There were no changes related to the Resident's significant decline in function since the MDS assessment of 6/20/15. Per observation and record review, the Resident was no longer independent with transfer or ambulating with supervision only. The Resident now required total care (the Resident was previously limited assistance). There were no interventions identified other than n psychoactive medication to addess the Resident's behaviors and condition, despite the ineffectiveness of the medicaions in manageing the behavior which had been continuously exhibited for 10 months since the Resident's admission to the facility. On 8/18/15 at 2:45 P.M., interview was held with the Administrator and the Director of Nursing to discuss the ineffective use of multiple psychoactive and antipsychotic medications, with excessive doses and adverse reactions Also discussed was an apparent decline in physical and mental function, without any alternative interventions being considered or implemented. No additional information was provided 2. For Resident #15, the facility failed to develop an individualized behavioral treatment plan with approaches for identified behaviors and only offered the Resident redirection and multiple psychoactive medications. The medical record failed to indicate a [DIAGNOSES REDACTED]. Resident #15 was a long term care resident admitted ,[DATE] with a [DIAGNOSES REDACTED]. The Resident was observed to be placed at a table with his/her head laying on the table and staff placing a face cloth under his/her head and when not by the table the Survey team observed the Resident slouched forward with his/her head almost touching his/her knees with both eyes closed A review of the significant change Minimum Data Set (MDS) assessment, dated 2/14/15, indicated the Resident had short and long term memory deficits, ws severely impaired with decision making and exhibited verbal behavioral symptoms. The assessment indicated the Resident rquired extensive assistancr from staff for activites of daily living and need set up assistance only for eating. The Care Area Assessment (CAA), dated 2/27/15, doucmented that the Resident had no functional range of movement impairments, wa able to eat independently, used a wheelchair and was able to self propel around the unit with an alarmed seat belt for safety. A review of the last quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the Resident had short and long term memory deficiits and was severely impaired with decision making and exhibited verbal behavioral symptoms. The assessment indicated the Resident needed extensiive assistance from staff for all activies of daily living. A review of the physician's orders [REDACTED]. The Resident received [MEDICATION NAME] (antidepressant) 22.5 mg. every day, Venlafaxane (Antidepressant) 37.5 mg. every day, Perphenazane (antipsychotic) 12 mg. every evening at hour of sleep and [MEDICATION NAME] (hypnotic)15 mg every evening at hour of sleep. Observations were as follows: - 8/11/15 lunch meal- Resident #15's eyes were closed. The Resident was significantly bent over with his/her head almost touching his/her lap. The Resident was removed from the dining room and placed in bed. The Resident could not self propel the wheelchair nor feed him/her self as assessed in the MDS dated [DATE]. - 8/13/15 lunch meal - Resident #15 was observed with his/her head on top of the table with a folded facecloth placed unde the head. The Resident alternately accepted liquids and then let other liquids offered drool out of his/her mouth. - 8/14/15 8:25 A.M. through 9:10 A.M. - The Resident was in the wheelchair with his/her head bent forward inches above the knees. At 8:40 A.M. the CNA approached and asked the Resident if he/she wanted some juice. The Resident did not respond and the CNA was observed to place the Resident's head on the table. The Resident sat there in the same position until 9:10 A.M. when he/she was taken to his/her room. During interview at 9:15 A.M. on 8/14/15, Staff Nurse #1 was asked if the Resident was alright. Staff Nurse #1 said that Resident #15 did this often as the Resident did not sleep during the night shift. Staff Nurse #1 said that the Resient worked as a nurse for years in the hospital on the night shift and his/her family stated that he/she was always up all night. - 8/18/15 breakfast meal - The Resident was in the wheelchair significantly bent at the waist with his/her head just above the knees and both eyes closed. A CNA was observed to approach and call the Resident name and gently patted his/her back. The CNA was then observed to spoon cereal and attempt to place in the Resident's mouth which was facing the fllor. The liquid spilled out of the Resident's mouth. After two additional attempts, the CNA got on her Haunches close to the floor and attempted to feed the Resident by bringing the spoon upwards from the floor to the Resident's mouth. The liquid spilled out of the Resident's mouth onto the floor. A review of the Psychiatry consult reports indicated the Psychiatrist saw the Resident at least every month. A review of the 1/6/15 note indicated the Resident was receiving multiple medications that included antipsychotic, antianxiety and antidepressant, and was now less anxious and noted the Resident had improved. There were physician's orders [REDACTED]. The next consult report dated 1/20/15 indicated the Resident was combative and still not sleeping at night. The psychiatry report recommended to discontinue the [MEDICATION NAME] and [MEDICATION NAME] and to start anotherr antipschotic medication Perpenazine 6 mg in the morning and 12 mg at hour of sleep for a totoal of 18 mg per day (which exceeds the recommended maximum dosage for the elderly of 8 mg in 24 hours). A psychiatry report dated 2/3/15 indicated the Resident is somewhat lethargic and recommended to change antidepressant medication from [MEDICATION NAME] to [MEDICATION NAME]. A review of the 3/24/15 report indicated that the Resident is up at night and often napping during the day and wrote to try to keep the resident awake during the day to reset sleep-wake cycle. The report had no information of the Resident's former lifestyle of being awake all night and why there was a need to change the sleep pattern. The next Psychiatry report dated 5/18/15, indicated the Resident had a dazed look to her. The next psychiatric consult report dated 6/22/15 indicated that the Resident napped all day and was up all night and recommended more medication changes for [MEDICAL CONDITION] which included to decreased the Perpenaxine to 12 mg daily and add another antidepressant, [MEDICATION NAME] 7.5 mg for [MEDICAL CONDITION]. The last Psychiatry consult report dated 7/27/15 indicated the Resident was still up at night and often sleeping during the day. The Psychiatrist recommended to increase the antidepressant [MEDICATION NAME] from 7/5 mg to 22.5 mg and to and add a hypnotic, [MEDICATION NAME] 15 mg every night for sleep. A review of the monthly behavior monitoring records from 4/2015 - 7/2015 indicated the following: - On 5/20/15 he/she yelled. - On 6/3/15 he/she was physically abusive. - On 7/3/15, 7/6/15, 7/10/15 physically abusive and on 7/17/15 yelled. A review of the nurses notes for the same time period for the above dates had no information to review of what the Resident specifically exhibited for behaviors on the above 5 dates in a four month period. The nurses notes for this time period had only one note documenting the Resident was up all night on 6/29/15. A review of the plan of care for behaviors, initialliy dated 8/2014 and last updated 5/14/15 and 8/14/15 indicated the problems and needs were the same as on admission with feeling restless, trouble expressing self, crying and depression, trouble sleeping and not liking to sleep in a bed. The identified problems were not changed and the plan had the same goal that the Resident would be able to express self and sleep all night. The action plan noted the Resident was a nurse for many years but did not address the night shift work. The plan had no behavioral interventions noted. The approaches had a full 3 pages of medication changes since admission from 8/2014 - 8/2015 but no specific interventions on how the facility staff were to care for the Resident when anxious or restless, and no plan developed for the his/her life long pattern of being up at night. A review of the medical progress notes indicated the following: - The Nurse Practitioner on 4/16/15 noted the Resident was sleeping and recommended to attempt to reverse sleeping habits. The progress note had no information of the Resident's life style of working and being up during the night hours. - The Nurse Practitioner on 6/9/15 noted the Resident continues with day time lethargy, being up on night and observed by the Practitioner to be slouched over, lethargic but arousable. - The Physician wrote a progress note on 6/10/15 that the staff may have the resident up in the night and let him/her rest during the day. There was no information in the medical record that the facility acted on the Physician's recommendation to let the Resident stay up at night. - The Nurse Practitioner on the first day of survey 8/11/15 noted the Resident continued to be up at night and sleeping during the day. During interview on 8/18/15 at 2:45 P.M., the Director of Nurse offered no information of any behavioral planning.

Based on record review, interviews, and observation, the Facility failed to ensure for one of three sampled residents (Resident #1), who where assessed to be at high risk for falls, that the safety bed pad alarm identified in Resident #1's Fall Risk plan of care, was appropriately used and functioning at the time of Resident #1's fall. On [DATE] at about 1:00 AM, Resident #1 was heard calling from Resident #1's room and upon entering Resident #1's room, the bed safety alarm was not sounding, and Resident #1 was observed on the floor, and bleeding from the head. A nurse's note dated [DATE] for the 11 PM to 7:00 AM shift indicated that Resident #1 sustained a hematoma to the right elbow and a 3 to 4 centimeter laceration to the back of the head for which Resident #1 was transferred to the Hospital and received 5 staples to the laceration. Findings included: Resident #1's clinical record indicated Resident #1 was admitted to the Facility December, 2005, and medical [DIAGNOSES REDACTED]. Resident #1's quarterly Minimum Data Set (MDS) resident assessment, signed and dated as completed on [DATE], indicated Resident #1 required extensive assistance of two persons for bed mobility and transfers. The MDS indicated that Resident #1 was always incontinent of urine, required extensive assistance of one person for ambulation, and Resident #1 experienced one fall in the past 6 months without injury. Resident #1's At Risk for Injury related to Falls plan of care, updated on [DATE], indicated interventions included: pressure alarm when in the bed and the chair, a low bed, non skid safe sturdy footwear, and one to one supervision when Resident #1 was extremely confused and delusional. The nurse's note, dated [DATE] at 4:45 AM, indicated Resident #1 was rolled up in the bedding and on the floor beside the bed. The nurse's note indicated no injuries were noted at this time. The Falls Committee review note, dated [DATE], indicated that at 4:45 AM, Resident #1 was found rolled up in the blanket on the floor beside the bed. The Falls Committee review note indicated Resident #1's pressure alarm had not sounded. The Falls Committee review report indicated the pressure alarm was replaced, and Resident #1's previous safety plan would continue as well as every 15 minute safety checks. On [DATE] at 1:40 PM, the Surveyor interviewed CNA #1. CNA #1 said CNA #1 worked from [DATE] at 11:00 PM until [DATE] at 7:00 AM, CNA #1 said Resident #1 was on 15 minute checks by nursing staff as part of Resident #1's care plan. CNA #1 said during the last resident bed check, CNA #1 observed Resident #1, who appeared to be sleeping and CNA #1 continued to complete the resident bed checks. CNA #1 said a resident required care, CNA #1 provided incontinence care to that resident which took no more than 10 minutes, and CNA #1 washed CNA #1's hands and proceeded to the supply closet. CNA #1 said as CNA #1 opened the supply closet, CNA #1 heard "ma, ma". CNA #1 said the closet was right across from Resident #1's room. CNA #1 said CNA #1 went into Resident #1's room and observed Resident #1 on the floor with Resident #1's head on the floor off the bedside mat. CNA #1 said Resident #1's head was towards the bureau at the foot of the bed. CNA #1 said CNA #1 called for help in Resident #1's room. CNA #1 said as the nurse attended to Resident #1, CNA #1 pressed on Resident #1's bed safety alarm pad as the pad had not activated. CNA #1 said when CNA #1 pressed on the bed alarm pad, the pad had not sounded during the testing of the pad. CNA #1 said on the second press of the pad, the pad sounded. CNA #1 said the alarm boxes attached to the bed pads were always 'on' and a light flashed. CNA #1 said at the beginning of the shift, the CNAS checked all bed alarms for proper functioning. CNA #1 said CNA #1 was not sure if the bed pads were dated but when checking the functioning of the alarms, staff checked for the blinking light on the alarm box and if residents were lying on top of the bed safety alarm pad. On [DATE] at 3:35 PM, the Surveyor interviewed CNA #2. CNA #2 said CNA #2 worked from [DATE] at 11:00 PM until [DATE] at 7:00 AM. CNA #2 said less than 10 minutes before Resident #1 was found on the floor, CNA #2 had observed Resident #1 sleeping in the bed because CNA #2 had answered a resident's call light and went by Resident #1's room, looking in at Resident #1. CNA #2 said CNA #2 heard CNA #1 call from Resident #1's room. CNA #2 said Resident #1's safety bed alarm was not sounding at that time. CNA #2 said when Resident #1's bed alarm pad was tested , it took two presses before the alarm activated. CNA #2 said when bed safety alarms were checked, one always looked for the blinking light on the alarm box. On [DATE] at 12:50 PM, the Surveyor interviewed CNA #3. CNA #3 said CNA #3 worked from [DATE] at 11:00 PM until [DATE] at 7:00 AM. CNA #3 said CNA #3 heard that Resident #1 had fallen and went into Resident #1's room. CNA #3 said CNA #3 observed Resident #1's green alarm box hanging from the side rail, the alarm pad was observed normally placed on the bed, and the switch of the alarm box was definitely in the "on" position. CNA #3 said CNA #2 tested the bed alarm pad and had to put a lot of pressure on the bed pad to make the bed pad sound. On [DATE] at 12:30 PM, the Surveyor interviewed Nurse #1. Nurse #1 said Nurse #1 worked from [DATE] at 11:00 PM until [DATE] at 7:00 AM. Nurse #1 said Nurse #1 was aware Resident #1 had a fall from the low bed on [DATE], and Resident #1's safety alarm box and pad were replaced at that time. Nurse #1 said when Nurse #1 was called to Resident #1's room on [DATE], Resident #1 was verbal and alert and bleeding from a head laceration. The nurse's note, dated [DATE] at 2:00 AM, indicated at about 12:45 AM, Resident #1 was observed sleeping in the bed. The nurse's note indicated at 1:00 AM, Resident #1 was observed to be on the floor at the bedside with bleeding from the head. The nurse's note indicated Resident #1's alarm was not sounding. The nurse's note, dated [DATE], indicated Resident #1's faulty alarm was replaced with new alarm. Nurse #1 said Family Member #1 accompanied Resident #1 on return from the emergency department on [DATE]. Nurse #1 said Family Member #1 stated Family Member #1 could not understand how a safety alarm could not "sound". Nurse #1 said Nurse #1 explained to Family member #1 that occasionally a safety alarm didn't sound when a person got out of the bed. Nurse #1 said Nurse #1 tried to assure Family Member #1 that Resident #1 was on 15 minute visual checks by staff, and that Resident #1 had been "found" right away after the fall. Nurse #1 said that Family Member #1 remained upset and Nurse #1 offered to call the Director of Nurses (DON) for Family Member #1 however, Family Member #1 was not satisfied with that response. Nurse #1 said Nurse #1 told Family member #1 that Family Member #1 should definitely contact the DON. On [DATE] at 2:05 PM and on [DATE] at 11:00 AM, the Surveyor interviewed Family Member #1. Family Member #1 said that initially, Facility staff told Resident #1's family member that Resident #1's safety bed alarm had not sounded when Resident #1 fell from the bed on [DATE], but when Family Member #1 reviewed the Facility's report to the Department of Public Health (DPH), after Resident #1's death on [DATE], the report indicated the alarm had sounded at the time of Resident #1's fall from the bed. Family Member #1 said the Facility report was amended to read that the bed alarm had not sounded on [DATE], at the time of Resident #1's fall from the bed. On [DATE], on multiple occasions, the Surveyor interviewed the DON. The DON said Resident #1's bed safety alarm had a turn off switch on the alarm box, as had Resident #1's previous safety alarm which was replaced on [DATE]. The DON said that although there was no evidence found that the turn off switch was not working, at the time Resident #1 fell , any safety alarm with that type of switch had been removed from use in the Facility since [DATE], and new safety alarms had been secured. On [DATE], the day of survey, the Surveyor was shown by the DON, the same type of bed sensor pad used by Resident #1 at the time of Resident #1's fall on [DATE]. The Surveyor measured the bed sensor pad, which measured 9.5 inches by 15 inches, and the pad had a picture on one side which indicated the sensor pad was a wheelchair/chair pressure pad. The sensor pad had not indicated bed usage.