**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide adaptive equipment for a resident when consuming liquids for 1 out of 2 sampled residents reviewed for adaptive equipment, affecting Resident #6. The findings included: Review of the facility's policy titled, Adaptive Feeding Equipment Policy and Procedure, with an effective date of 09/25/24, included in part, the following: To provide adaptive equipment to obtain and/or maintain a resident highest practicable level. Residents requiring assistance in feeding are potential candidates for a restorative dining program or adaptive utensil use, as determined by the occupational therapist. The dietary department should be notified of residents needing adaptive feeding equipment; the equipment is stored and maintained in the dietary department. Appropriate utensils should be placed on the resident's food tray, at each meal, and returned to the dietary department, on the food tray, for sanitization. Record review for Resident #6 revealed the resident was originally admitted to the facility on [DATE], with readmission on [DATE], with diagnoses that included, in part, the following: Anoxic Brain Damage, Dysphagia, Other Speech Disturbances, and Electrocution. Review of the Minimum Data Set assessment for Resident #6 dated 11/07/24 documented in Section C that a Brief Interview of Mental Status was not completed, due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #6 revealed an order dated 05/31/17 for NAS (No Added Salt), Pureed, and No straw. Review of the Physician's Orders for Resident #6 revealed an order dated 03/11/22 for aspiration precautions: 90 degrees all meals, no straws, and small bites/sips. Review of the Physician's Orders for Resident #6 revealed an order dated 07/17/23 for adaptive equipment - nosey cup with liquids, to enhance feeding. Review of the Care Plan for Resident #6 dated 11/19/24 with a problem of resident is at risk for alteration in nutrition/hydration and weight fluctuations related to impaired cognition secondary to anoxic brain damage, other abnormal involuntary movements, and vary PO (oral) intake. He is at increased risk for aspiration related to diagnosis of dysphagia and needed mechanically altered diet. The goal was for the resident to maintain weight within the healthy BMI (Body Mass Index) range (18.5-24.9) via monitor of weight report. He will continue to consume >50% of meal provided and nutritional supplement acceptance via daily PO intake observation. No noted s/s (signs/symptoms) of aspiration via daily observation. The approaches included, in part, the following: Adaptive equipment: Nosey cup with liquids to enhance feeding. And NAS/Puree texture/thin liquids diet, no straw. He is fed by staff. On 12/09/24 at 10:15 AM, observations revealed Resident #6 in his room, sitting up in a chair with a rolled washcloth in each hand wearing hand splints. Further observations revealed a Styrofoam cup containing water, sitting on the nightstand. There was no nosey cup at the bedside. On 12/09/24 at 12:10 PM, a second observation was made of Resident #6 in his room, with a Styrofoam cup containing water, at bedside. No nosey cup was observed. On 12/09/24 at 12:30 PM, observation was made of Resident #6 with a lunch tray brought into his room, containing apple juice and one nosey cup. Staff A, Certified Nursing Assistant (CNA) was assisting Resident #6 with eating. An interview was conducted on 12/09/24 at 12:32 PM with Staff A, who stated she has worked at the facility for 10 years. When asked about the nosey cup on the Resident #6's lunch tray, she said the resident needs the nosey cup to drink all liquids. On 12/12/24 at 9:56 AM, a side-by-side observation was made with Staff B, Nursing Manager, in the room of Resident #6, who acknowledged the resident had a Styrofoam cup with a straw, full of water at the bedside. There was no nosey cup observed. An interview was conducted on 12/10/24 at 9:50 AM with Staff C, Registered Nurse (RN), who stated she has worked at the facility since 2017. She was asked if a resident has adaptive equipment for a special cup, would the resident need the special cup for water at the bedside. She stated, when the resident has an order for adaptive equipment, it comes with the meals from the kitchen. When asked would the resident need the adaptive equipment for any liquids at the bedside, she said it would have to come from the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 06/01/22 at 9:25 AM, an observation of medication administration was conducted with staff B on Resident # 58. Staff B administered 1 tablet of Multivitamin with mineral without a physician order, and Staff B omitted the Vitamin D3 1000 unit that was ordered to be administered at 9 AM. Staff B had administered the following medications to Resident #58: Multivitamin with Mineral 1 tablet by mouth; Baclofen 10 mg 1 tablet by mouth; and Aspirin 81 mg 1 tablet by mouth, for a total of 3 pills which was confirmed with Staff B before the administration. After the medication administration, the medications were reconciled and compared against the orders and the scheduled medications. It was revealed that there was no order for Multivitamin with Mineral that Staff B had administered, and the Vitamin D3 1000 unit, that was scheduled to be administered, was omitted. Once the surveyor questioned Staff B about these meds, Staff B, acknowledged the errors, she removed the Vitamin D3 1000 unit out of the medication cart and administered it to Resident #58. Record review revealed Resident #58 was admitted to the facility on [DATE], the quarterly Minimum Data Set (MDS) assessment reference date 03/23/22 documented a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact. On 06/02/22 at 3:01 PM, an interview was held with the Director of Nursing (DON), she voiced she was made aware of the medication error by the attending nurse and the nurse was in-serviced. Based on observation, interview and record review, the facility failed to ensure the medication error rate was not 5 percent or greater. The medication error rate was 11.11 percent. Three medication errors were identified while observing a total of 27 opportunities, affecting 2 of 6 sampled residents observed (Residents #45 and #58). The findings included: 1) A medication pass observation for Resident #45 was made on 06/02/22 beginning at 8:28 AM with Staff A, a Registered Nurse (RN). The RN obtained eleven medications, to include nine pills, a patch, and an eye drop. The RN also poured a nutritional supplement. The medication prepared by the RN was as follows: a) Amlodipine 10 mg (milligrams) - one tablet b) Calcium 600 mg - one tablet c) Vitamin B12, 250 mcg (micrograms) - one tablet d) Bisacodyl 5 mg - two tablet e) Ferrous Sulfate 325 mg - one tablet f) Lidocaine Patch 5% g) Miralax 17 gm (grams) - powder mixed in water h) Morphine Sulfate ER (extended release) 60 mg - one tablet i) Ocuvite - one tablet j) Systane Lubricant eye drops k) Vitamin D3, 50 mcg/2000 IU (international units) - one tablet l) ProHeal 30 ml (milliliters) - liquid nutritional supplement When asked if that was all that was due for this medication pass for Resident #45, the RN stated it was. The RN was asked to count the number of pills she had obtained for administration to Resident #45, as a way to verify the surveyor's documentation . The RN counted out nine pills, informing the surveyor she had poured out two of the Bisacodyl for administration. Staff A, the RN, administered the above medications and supplement to Resident #45. During reconciliation of the medications with the physician orders, the record documented the order for Oxybutynin Chloride ER 10 mg daily. Review of the corresponding Medication Administration Record (MAR) revealed Staff A had signed out the medication as administered. During an interview on 06/02/22 at 11:34 AM, when asked about the Oxybutynin that was ordered for daily administration, the RN stated, It was in there. The surveyor reviewed with Staff A the medications pulled from the medication cart for Resident #45, confirming the nine pills. The RN again stated she thought the Oxybutynin was in the medications that she had obtained from the cart, but agreed it could not have been. Staff A agreed with the medication error.