Based on observations, staff interviews, and review of the facility policies titled Food Preparation and Distribution, and Ice Chests and Ice Machines, the facility failed to ensure the proper sanitation of equipment, removal of outdated food, and proper storage of open food in the kitchen. The deficient practices had the potential to place residents who received an oral diet at risk of foodborne illnesses. Findings Include: Review of the facility policy titled Food Preparation and Distribution, review date 12/27/2024, revealed the Intent section stated, It is the intent of this center to prepare and distribute food in a manner that minimizes the risk of food-borne illness and promotes safe food handling practices. The Guideline section included, . Work surfaces and equipment should be cleaned and sanitized as needed. During preparation of modified consistency foods, safe food handling practices should be followed. Review of the facility policy titled Ice Chests and Ice Machines, review date 12/27/2024, revealed the Intent was To assure patient safety in use of ice and ice machines. The Guidelines section included . Clean, disinfect, and maintain ice-storage chests on a regular basis. Observation on 2/11/2025 at 8:57 am of the walk-in cooler revealed a package of polish sausage with a use-by date of 2/7/2025. Further observation revealed packages of opened, unwrapped, and undated sausage patties and bacon. Observation on 2/11/2025 at 9:18 am of the dry storage pantry revealed five bags of chips with a use product date of 1/28/2025. Further observation revealed an opened and unsealed package of macaroni noodles. Observations on 2/11/2025 at 9:24 am in the kitchen revealed pureed food in the puree blender sitting on the counter, and the mixer and slicer were observed to have food particles on the machines. Observation on 2/11/2025 at 9:40 am revealed the ice machine had a black flakey substance on the inside handle. In an interview on 2/11/2025 at 11:15 am, the Dietary [NAME] confirmed the pureed food was left in the puree blender sitting on the counter. She stated the food should not be left sitting at room temperature. In an interview on 2/12/2025 at 9:10 am, the Dietary Manager (DM) confirmed the pack of polish sausage was out-of-date, the sausage patties, bacon, and noodles were opened and undated, and the chips were past the expiration date. The DM further verified the pureed food was left in the puree blender on the counter and stated it should not be left sitting at room temperature. The DM verified the ice machine had a black, flaky substance on the inside handle. The DM stated the facility policies should be followed in the kitchen.

Based on observation, interview, and record review, the facility failed to ensure one of twenty residents (R) (R43) reviewed had the equipment required to exit their room as desired to attend activities. This failure had the potential to affect any resident that requires a bariatric wheelchair. Findings include: Interview on 09/19/2023 at 10:20 am, R43 stated she was unable to get out of her room and wanted to attend activities. Review of the Electronic Medical Record (EMR) for R43 under the Resident tab showed a medical diagnoses that included hemiplegia and hemiparesis following a cerebral infarct, convulsions. Review of the quarterly Minimum Data Set (MDS) for R43 dated 08/22/2023, showed a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicative of being cognitively intact. Review of the activities participation documentation showed R43 attended bingo via Zoom during the month of August and September 2023. Review of the care plan located in the EMR under the care plan tab, dated 05/09/2023, noted Care Area/Problem: Needs assistance to participate in activities with an intervention of Assist with transportation to/from activity settings. Also, on 05/09/2023, a Care Area/Problem: Expresses past and/or present activity interests (strength) with a Goal: Patient will take part in preferred activities of interest during the review period and an intervention of Provide assist to/from activities of interest as needed. Interview on 09/20/2023 at 3:20 pm, the Activities Director (AD) stated R43 attended bingo via Zoom on a tablet. Observation with the Director of Nursing (DON) on 09/21/2023 at 9:56 am, Certified Nurse Aide (CNA) 2 un-collapsed R43's wheelchair and took it to the door. The entire set of left sided wheels were on the left side of the door frame opening. While in the room, R43 stated she didn't leave her room, and that activities would bring a tablet to her to participate in bingo. As we exited the room, the DON responded to the query of how long R43 had been confined to the room stating she didn't know. Review of facility provided wheelchair invoices on 09/21/2023 at 1:13 pm, the Administrator stated the secondary invoice showed he contacted a vendor regarding the fact the wheelchair did not fit through the door. The original chair was ordered on 06/28/2023. The second invoice (same order, updated) showed an anticipated ship date of 08/07/2023; and a note that on 08/11/2023 the Administrator called requesting to return the wheelchair as the wheelchair did not fit through the doorway. During a follow-up call on 09/21/2023 at 11:17 am, with the wheelchair vendor stated the Administrator started the return, processed on 8/11/2023, but the vendor denied the return. After checking the account, the vendor stated there was no reciprocal order on the account for a different wheelchair. Interview on 09/21/2023 at 4:30 pm, the Division Regional Nurse (DRN) stated a wheelchair was being delivered today for the resident. In a follow-up interview on 09/21/2023 at 6:17 pm regarding a policy for resident mobility or accommodation of needs, the DRN stated there was no policy.

Based on record review, staff interviews, and a review of the facility policy titled Abuse Policy, the facility failed to ensure that an allegation of resident to resident physical abuse was reported to the State Agency (SA) for one of one resident (R) (35) reviewed for reporting in a timely manner of 20 sampled residents within the required two hours of discovery. Findings include: Review of facility's policy titled Abuse Policy with a review Date of 12/30/2022, revealed If reasonable suspicion of a crime resulting in serious bodily injury is identified, police notification should occur within 2 hours. If reasonable suspicion of a crime is identified without seriously bodily injury involved, then police notification should occur within 24 hours. Review of facility investigative report dated 08/07/23 revealed R35's had a diagnoses of hallucinations, delusional disorders, legal blindness, and other psychotic disorder not due to a substance or known physiological condition. Review of R35's quarterly Minimum Data Set (MDS) found in the MDS tab of the electronic medication record (EMR) with Assessment Reference Date of 08/16/23 revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 which indicated R35 was cognitively intact. No alterations in mood were coded and R35 was coded zero for physical, verbal, or other behavioral signs and symptoms. Review of the facility's Incident Investigation provided on paper, dated 08/07/23, revealed On 08/03/2023 at. [approximately] 7:30pm after visiting with another resident in the hallway, [R35] went to his room to lie down. This room has three beds and [R35] is in the last bed. R 35 is legally blind, and instead of lying down in his bed he laid down on [R37's] bed. [R37] was in the chair next to the bed. This is when [R37] tried to physically remove [R35]. [R35], not understanding what was going on, yelled and pushed tried to push [R37] off of him. Staff came into the room and immediately separated the residents . An investigation was initiated by the Administrator immediately upon notification of the incident. The Administrator interviewed both residents. They both agreed that it was a misunderstanding, and they want no further action on it. Both had physical skin assessments done. Physician was notified. [R37] had a scratch on his neck that was treated. [R35] complained about left shoulder pain, which is chronic in nature. [R35] had an X-ray done and found no issues and was given a referral for physical therapy to be evaluated. [R35] went to another room for the night. The next morning, [R37] decided to change rooms . After investigation, the facility acknowledges [R37] and [R35] did have resident-to-resident mistreatment. The pharmacy consultant reviewed all medications on the resident. Both residents are enrolled into Geriatric Behavior services and will consult on August 10th. Social services interviewed residents to see if they feel safe. None reported any issues. During an interview on 09/20/23 at 6:00 PM, the Administrator stated that he did not consider the resident-to-resident physical altercation abuse. The Administrator stated that he had followed the National Long Term Care Ombudsman Resource Center guide on preventing and responding to resident-to-resident mistreatment during the investigation. The Administrator stated that he had not referenced the federal regulatory requirements. The Administrator confirmed that the police had not been notified of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility's policy titled ADL [Activities of Daily Living] Plan of Care, reviewed 12/30/22, showed: Intent. Develop and communicate patient needs for assistance with ADLs. Guideline. -Resident's ADL needs are assessed on admission and are addressed on the Baseline Care Plan and communicated to staff. -Nursing develops the patient's ADL care plan and will communicate the level of assistance required for the patient. -The ADL care plan will be updated in conjunction with the comprehensive care plan as required per regulatory and RAI [Resident Assessment Instrument] guidance and with changes in patient needs. 3. Record review of the EMR for R44 revealed a medical diagnoses that included quadriplegia, anxiety disorder, and major depressive disorder. Record review of the most recent quarterly MDS dated [DATE] revealed R44 had a BIMS of 11 indicating moderate cognitive impairment. Observation and interview on 09/19/2023 at 10:19 am, R44's bed was noted to have bilateral assist bars on her bed. R44 stated she didn't use them. Record review of the care plan for R44 located in the EMR showed a focus of limited mobility due to quadriplegia and was noted to require assistance with moving from a lying to a sitting position at the side of the bed but did not include any interventions noting the use of bed assist bars for bed mobility. Based on observation, record review, interviews, and a review of the facility policy titled, Skilled Nursing Services Patient's Plan of Care and ADL [Activities of Daily Living] Plan of Care, the facility failed to develop and implement comprehensive person-centered care plans for three residents (R) (50,112, and 44) of 20 sample residents reviewed for care plans. R50 did not have a comprehensive care plan addressing dental needs, vision, and bed rails; R112 did not have a comprehensive care plan addressing dental needs, restorative services, and pain management; and R44 did not have a comprehensive care plan addressing bed rail use. Findings include: Review of the facility's policy titled Skilled Nursing Services Patient's Plan of Care with a review date of 12/20/22, revealed the facility had a policy to ensure that each patient would have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs. 1. Record review of the admission Minimum Data Set (MDS) for R50 dated of 07/30/2023 located in the MDS tab of the EMR, revealed R50 had a Brief Interview for Mental Status (BIMS) score of 12 (indicating moderate cognitive impairment). R50was coded as having adequate vision, no broken teeth or tooth fragments, and was able to move about in bed with assistance and transfer with the help of two persons. Record review of the care plan for R50 in the Electronic Medical Record (EMR) revealed no dental needs care plan, vison care plan, or bed rail care plan. Observation on 09/19/2023 at 12:21 pm quarter rails were observed on R50's bed. In an interview, R50 stated she was unable to use them. R50 stated that she needed a dental appointment but could not pay for it and needed a follow up appointment for her vision. R50 stated that she previously saw an eye doctor and thought she was supposed to have cataract surgery but had not been told what would happen. R50 stated she had difficulty with her vision and had closed the blinds over the window to keep the glare out. Interview on 09/21/23 at 10:28 am the Director of Nurses (DON) stated she would look for R50's care plans for dental, vision and bed rail. No care plans were presented. 2. Record review of the admission MDS for R112 dated 09/03/2923 located in the MDS tab of the EMR revealed a had a Brief Interview for Mental Status (BIMS) score of 15 (indicating little to no cognitive impairment). The MDS revealed that the resident had pain almost constantly, pain affected her daily activities and her ability to sleep at night. The worst pain was rated as a 10 on a one to 10 scale. Review of the Care Area Assessment (CAA) revealed pain was triggered for further assessment. R112's pain disturbed her sleep, limited day to day activities, and limited independence with at least some activities of daily living. She received insufficient pain relief as pain relief occurred, but the duration was not sufficient, resulting in breakthrough pain. The CAA further revealed dental was triggered for care planning. Resident had broken teeth which she stated happened last year-resident denied pain/discomfort. The resident saw a dentist prior to admission to the facility and would see the resident while in facility. The resident did have Diabetes Mellitus (DM) and took medication which could impact oral health. Record review of care plan under in the EMR revealed there was no care plan for dental needs. Interview on 09/21/2023 at 10:28 am the Director of Nurses (DON) stated she would look for R112's dental care plan. No care plan was presented. Record review of the Medication Administration Record (MAR) for R112 dated 09/2023 revealed R112 expressed pain several times during the month rated at 10 out of 10, and tramadol (pain medication) was given as ordered to address the pain. Medication order for tramadol 50 mg (milligram) tablet give one tablet by mouth every eight hours as needed for pain with a start date of 09/04/2023. Interview on 09/19/2023 at 11:28 am, with R112 stated that her dental bridge broke during a fall prior to admission and that she could feel the screws remaining from the bridge in her mouth. R112 stated that she took pain medication and that there had not been any facility action yet to make a dental appointment. Record review of the nurses' notes tab in the EMR revealed on 09/20/2023, the resident was complaining of the screws on the bridges in her mouth hurting her mouth. The note documented, Will inform oncoming nurse and put on clinical dashboard that resident needs to see a dentist asap [as soon as possible]. Review of the comprehensive care plan, located in the EMR, revealed no care plan addressing the resident's pain management needs. Interview on 09/21/2023 at 10:28 am the Director of Nursing (DON) stated she would look for R112's pain care plan and confirmed there should have been a plan addressing R112's pain. No care plan was presented. Record review of R112's Physical Therapy (PT) note found under Therapy tab in EMR dated 08/29/2023 revealed R112 had a past medical history reason for referral. R112's PT evaluation was completed on 08/29/2023. R112 was referred for skilled PT for establishment of restorative program to further maintain current functional status. Record review of the restorative flowsheet dated 09/01/2023-09/18/2023 for R112 in the EMR revealed a plan for OMNICYCLE training for BLE (bilateral lower extremity) strengthening and coordination x 15-20 minutes with 0-2 resistance. Provide rest periods as needed. Documentation for 15 minutes was completed on 09/02/2023-09/14/2023, and 09/17/2023.There was no documentation on 09/15/2023-09/16/2023, and on 09/18/2023. Record review of the care plan located in the EMR revealed no restorative care plan. Interview on 09/21/2023 at 10:28 am the DON stated she would look for R112's restorative care plan. No care plan was presented.

Based on record review and interviews, the facility failed to review and revise care plan interventions for one of four residents (R) (53) reviewed for fall prevention of 20 sample residents. This failure had the potential to delay appropriate interventions for care needs and safety concerns. Findings include: Record review of the care plan dated 09/16/2023 revealed fall interventions to include the resident in the activities program, to the assist patient with activities of daily living (ADLs) 08/21/2023 and to assist with mobility as needed, to keep the bed in a low position 08/20/2023, to keep the call light in in reach 08/20/2023, to decrease stimuli, to encourage rest periods 8/20/2023, to provide appropriate footwear such as non-skid socks 8/20/2023, to keep her personal items within reach 8/20/2023, to redirect her as needed , to remind the patient to call when needing assistance, and provide a toileting schedule for the resident. 8/20/2023. Record review of the nurse's notes for R53 dated 09/18/2023 at 12:57 pm, revealed that a Certified Nursing Assistant (CNA) reported that R53 had attempted to sit in chair and fell on her bottom. The CNA stated that R53 complained of bilateral hip pain. The Nurse Practitioner was notified regarding R53's fall and her pain. An order was given for an X-ray of her bilateral hip and to conduct neuro checks. Review of Event Initial Note, dated 09/18/2023, revealed a fall on 09/18/2023 with no injury. A new care plan fall prevention intervention was not added. Review of Event Initial Note, dated 09/20/2023, revealed R53 had a fall on 09/20/2023. A new care plan fall prevention intervention was not added. Under the new intervention added after the event section a comment was made that [R53] has dementia and does not remember to ask for assistance and wanders around the room. Interview on 09/21/2023 at 11:03 am with Director of Nursing (DON) regarding fall prevention interventions in place for R53 related to two falls this week on 09/18/2023 and 09/20/2023, the DON stated that the resident was hard to redirect due to cognition. The DON acknowledged that reminding the resident to call when needing assistance was not an appropriate intervention. DON did not offer additional interventions related to the falls on 09/18/2023 and 09/20/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and a review of the facility policy titled Care of Fingernails/Toenails, the facility failed to provide assistance with nail care to preserve and promote the dignity of two residents (R) (21 and R57) of four residents reviewed for activities of daily living out of 20 sample residents. This failure resulted in residents' appearance that did not maintain the resident's dignity. Findings include: Review of the facility policy titled Care of Fingernails/Toenails, reviewed 12/30/22, showed: Intent. It is the intent of this center to provide appropriate nail care to patients. Procedure. -Use appropriate hand hygiene/hand washing as situation dictates before beginning the Procedural Guidelines. -Assemble the equipment and supplies that should be necessary to perform the Procedural. Guidelines and take them to the patient's room. -Knock before entering the room. -Place the equipment on the bedside stand or over bed table. -Arrange the supplies so they can be easily reached. -Identify yourself. Ask the patient's permission to perform the nail care. Explain the Procedural Guidelines to the patient. -Pull the cubicle curtain around the bed for privacy. -Gently, clean under each nail. Soaking hand /foot before cleaning may be appropriate. -Trim the fingernails/toenails. -Smooth with nail file or emery board if needed. -Clean the bedside stand or over bed table if needed. -Clean the nail clipper. -Use appropriate hand hygiene/hand washing as situation dictates. 1. Record review of the Electronic Medical Record (EMR) Resident tab showed a medical diagnoses that included hemiplegia and hemiparesis following cerebral infarct, congestive heart failure, osteoarthritis, anxiety disorder, and hypertension. Record review of the most recent quarterly Minimum Data Set (MDS) for R21 dated 06/07/2023 showed R21 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicative of being cognitively intact. R21 was totally dependent on staff for personal hygiene. Interview and observation on 09/18/2023 at 4:09 pm it was noted R21 had long fingernails. When queried about the length of his fingernails, R21 confirmed he needed his nails trimmed. Observation on 09/21/2023 at 2:46 pm along with the Director of Nursing (DON) R21's hands were confirmed to have long nails. R21 stated he wanted to go back to room. The DON started pushing him back and the resident stated he was needing his nails shorter because they got in the way. 2. Record review of the EMR for R57 revealed a medical diagnoses that included disorganized schizophrenia, skull fracture, muscle weakness, need for assistance with personal care, traumatic subarachnoid hemorrhage, and dementia. Record review of the most recent quarterly MDS dated [DATE] for R57 had a BIMS score of 12 out of 15, indicative of moderate cognitive impairment. R57 was assessed as requiring supervision/oversight with set up help for personal hygiene. Interview and observation on 09/18/2023 at 11:46 am, R57's fingernails were noted to be long. When asked if long nails were his preference, R57 stated he needed his nails trimmed. When asked if staff helped with nail care, R57 stated, No, but they need to, my toenails too. Follow-up observation and interview on 09/21/2023 at 2:42 pm showed the nails remained long and R57 again confirmed his fingernails need cut and my toenails too. During a follow-up observation and interview with the DON and R57 on 09/21/2023 at 2:50 pm, the DON confirmed R57 had long nails. R57 stated he did not want to have long nails and his toenails are too long too. The DON expressed an expectation that resident nails were to be trimmed on shower days unless the resident was a diabetic and then it was different. During an interview on 09/21/2023 at 5:50 pm, Certified Nurse Aide (CNA) 1 stated nail care was to be done on shower days. When queried what happened if the resident refused showers, CNA1 stated We can still do nail care. When asked what nail care was done if the resident received a bed bath, CNA1 responded, It's still to be done. During an interview on 09/21/23 at 6:00 pm, the Administrator expressed that if the resident requested or needed nail care it was his expectation that he expected it would be done.

Based on observations, record review, and staff interview, the facility failed to ensure one resident (R) (27) of four residents reviewed for limited range of motion of 20 sample residents received restorative services as needed to address limited range of motion in his right arm. This created a potential for worsening contracture (fixed resistance to passive stretch), pain, or skin breakdown. Findings include: Record review of the Electronic Medical Record (EMR) revealed a diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affecting the right dominant side. Record review of the most recent quarterly Minimum Data Set (MDS) for R27 dated 08/20/2023 revealed R27 required extensive assistance with bed mobility, dressing, and toilet use and required total assistance with personal hygiene. R27 had limited range of motion on one side in the upper and lower extremities. Observation on 09/19/2023 at 9:11 am, R27 was in his bed, holding his right arm with his left hand. R27's right arm was bent at a 90-degree angle and the hand was balled in a fist. R27 was unable to move his right arm. There was no splint or protection device on the elbow or hand. Record review of R27's active Physician's Orders, located in the Orders tab of the EMR, revealed there was no order for restorative services. Review of the Occupational Therapy Discharge Summary, dated 12/15/2021, located under the Therapy tab of the EMR, revealed a functional maintenance program of exercise and range of motion services was established with the facility's restorative nursing program. Review of R27's nurse practitioner's Progress Note, located in the Scan Docs tab of the EMR, dated 08/07/2023, revealed Contracture of right upper arm - 90 degrees at elbow. No swelling or erythema. Monitor for changes in joint/contractures and refer to OT [occupational therapy]/PT [physical therapy] as indicated. Review of R27's Care Plan, located in the Care Plan tab of the EMR, dated 09/05/2023, revealed he experienced decreased range of motion and contracture. The goal was, Patient will maintain functional mobility and accept assistance with physical function in bed mobility, transfer, locomotion, and ROM [range of motion] during the review period. The approaches included: Assist with ADLs [activities of daily living] as needed . Provide appropriate level of assistance to promote safety of resident . Provide cues as needed . Refer to Therapy as indicated . [and] See Restorative POC [plan of care]. Review of the Restorative tab of R27's EMR revealed the POC goal, Patient will maintain adequate AROM [active ROM] and strength in L [left] UE [upper extremity] and PROM [passive ROM] on R [right] UE to allow daily participation in mobility and other functional/ADL activities, and to decrease the risk of injury and prevent contracture development in R UE. The interventions included: Provide moderate resistance exercises in L UE using green [resistance band] for 10 reps [repetitions] x 2 sets each plane and provide gentle PROM exercises in R UE to patient's tolerance for 10 reps each plane. Review of R27's April 2023 to September 2023 restorative Participation Record revealed there were no restorative services provided during the six-month period. During an interview on 09/21/2023 at 10:28 AM, the Director of Nursing (DON) stated the facility had been having an issue with restorative. She stated R27's restorative program had been discontinued but was unable to find documentation to indicate why the program was stopped. During an interview on 09/21/2023 at 2:49 PM, Certified Nurse Aide (CNA)5 stated R27 was not on a restorative program. She stated he received passive range of motion when she assisted him with putting on his shirt or other ADLs but did not receive any formal or documented range of motion services. CNA5 stated R27 was unable to move his right arm or hand. During an interview on 09/21/2023 at 4:40 PM, the DON stated she believed R27 had been discharged from the restorative program based on an OT recommendation; however, the OT stated he needed to be on a restorative program for range of motion and was going to re-instate the program. During an interview on 09/21/2023 at 5:23 PM, the OT stated he worked with R27 in 2021 and discharged R27 from therapy on 12/15/2021. The OT stated at discharge, he recommended a restorative program for R27 for range of motion services. The OT stated the restorative program established upon OT discharge was still appropriate for R27, as he had not heard of any changes or a need to make a reassessment. The OT stated he did not know why the restorative program for R27 was discontinued and he had not seen R27 since 12/15/2021. The OT stated R27 should have been on a restorative program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure appropriate fall interventions were implemented resulting in continued falls for one (Resident (R) 53) of four residents reviewed for falls. This failure presented a potential risk for increased falls and physical injury. Findings include: Review of R53's Face Sheet tab found in the electronic medical record (EMR) revealed the following diagnoses: Alzheimer's disease, hypertension, iron deficiency anemia, type 2 diabetes mellitus, and dementia. Review of R53's quarterly Minimum Data Set (MDS) found in the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 07/14/23 revealed she was unable to complete the Brief Interview for Mental Status (BIMS) and staff assessment revealed memory problems and severely impaired cognition. She occasionally rejected care but had no other behavioral symptoms. R53 required limited assistance with transfers, bed mobility, and walking and required extensive assistance with toileting. R53's balance was not steady, and she was only able to stabilize with assistance. She used a walker for mobility. Review of Event Initial Note provided on paper by the DON dated 12/08/22, revealed R53 had a fall on 12/08/22. She had a bruise on the right hand as a result of the fall. A new care plan fall prevention intervention was added to include R53 in activities. Review of Event Initial Note, provided on paper by the DON dated 02/08/23, revealed R53 had a fall on 02/08/23. She had a head injury to her lateral right eye area. A new care plan fall prevention invention was added to include placing R53 in an open area of the facility for maximum observation opportunities. Review of Event Initial Note, provided on paper by the DON dated 02/26/22, revealed R53 had a fall on 02/26/23 and there was no injury. A new care plan fall prevention intervention was added to decrease stimuli for R53. Review of Event Initial Note, provided on paper by the DON dated 03/25/23, revealed R53 had a fall on 03/25/23 and did not have an injury. A new care plan fall prevention intervention was added to provide redirection for R53. Review of Event Initial Note provided on paper by the DON, dated 08/20/23 revealed R53 had a fall on 08/20/23 and there was no injury. There were care plan fall prevention interventions added which included placing the bed in low a position to the floor making sure the call light in her reach, encourage her to take rest periods, and to provide her with footwear, such as nonskid socks and start a toileting schedule for her. Review of R53's Resident's Data Collection tab of the EMR revealed R53 fell on [DATE] from her bed and slipped down to the floor. Record review of R53's nurses notes found under the Nurses Notes tab of the EMR, dated 09/18/23 revealed R53 was alert and verbal afterwards, and that no injury was noted from fall on 09/18/23. R53 was ambulating in her room without difficulty, denied pain at this time, and nursing staff would continue to monitor R53. Review of R53's nurse's notes found under the Nurses Notes tab of the EMR, dated 09/18/23 revealed R53 was alert and verbal. She was ambulating in her room without difficulty. The X-ray results were received and there were no new orders for R53. Nursing staff will continue to monitor. Review of R53's nurse's notes found under the Nurses Notes tab of the EMR, dated 09/18/2023 at 12:57 PM revealed that a Certified Nursing Assistant (CNA) reported that R53 had attempted to sit in chair and fell on her bottom. The CNA stated that R53 complained of bilateral hip pain. The Nurse Practitioner was notified regarding R53's fall and her pain. An order was given for an X-ray to her bilateral hip and to conduct neuro checks. Review of R53's nurse's notes found under the Nurses Notes tab of the EMR, on 09/19/23 revealed R53 fell on 9/18/23 and an X-ray was performed. There were no results mentioned in the nurse's note. Review of R53's Event Initial Note provided on paper by the DON dated 09/18/23 revealed a fall on 09/18/23 with no injury. A new care plan fall prevention intervention was not added. Review of Event Initial Note dated 09/20/23 revealed R53 had a fall on 09/20/23. Under the new intervention added after the event section a comment was made that R53 had dementia and did not remember to ask for assistance and wandered around the room. During an interview on 09/21/23 at 11:03 AM the DON stated that R53 was hard to redirect due to impaired cognition. The DON acknowledged that reminding the resident to call when needing assistance was not an appropriate intervention and the interventions in place were ineffective. DON did not offer additional interventions related to the falls on 09/18/23 and 09/20/23. The DON stated the facility used to perform a root cause analysis of each fall in order to determine appropriate interventions to prevent a recurrence; however, they had not done it in a long time.

Based on interview and record review, the facility failed to ensure two of two eligible Certified Nurse Aides (CNAs) 1 and CNA 4 had an annual performance review completed to enable in-service education based on the outcome of the reviews. This failure could affect the skills and knowledge required to correctly and efficiently provide care for residents. Findings include: Review of two CNA personnel files, chosen for a hire date greater than twelve months prior to the review showed the following data: CNA 1: Date of Hire 06/17/21 and had an Associate Performance Appraisal dated 06/12/23. CNA 4: Date of Hire 10/06/21 and had an Associate Performance Appraisal dated 10/12/22. The Associate Performance Appraisal had the following categories and sub-areas graded as Consistently Superior, Consistently Satisfactory, or Consistently Unsatisfactory: -Quality if work (accuracy, neatness, and ethical); Quantity of work (productivity and teamwork); Dependability (follows instructions, judgement, punctuality, attendance, and helpful); Cooperation (with supervisor, with fellow employees, inspires others, and innovative); Initiative (ingenuity, self-reliance, planning, ambition, and compassion); Self-Improvement (interest, observation, questions, study, and attitude); and Personality (appearance, courtesy, friendliness, and expression). The form did not include any performance reviews regarding areas of in-service education required to address improvement in areas of care provision weaknesses, special resident needs, and needs of residents with cognitive impairment. During an interview on 09/21/23 at 6:00 PM regarding expectation of annual performance reviews, the Administrator confirmed the current review did not meet the regulation, stating, It's going to be where the annual review will assess skills so we can work towards those issues. During an interview on 09/21/23 at 6:17 PM regarding a policy for annual performance reviews, the Division Regional Nurse stated there was no policy.

Based on observation, interview, record review, and a review of the facility policy titled, Dental Services/Oral Assessments, the facility failed to assist two of eight residents (Resident (R) 50 and R112) reviewed for dental services in obtaining routine dental care out of 20 sample residents. Findings include: Review of facility's policy titled, Dental Services/Oral Assessments, with a review date of 12/30/22, revealed that the facility would assist residents obtain dental services by making appointments and arranging transportation and that they would perform oral assessments on admission, annually, and as needed. 1. Review of R50's Face Sheet tab located on the home page in the electronic medical record (EMR) revealed diagnoses which included cerebral infarction, unspecified, type 2 diabetes mellitus with diabetic nephropathy, chronic diastolic (congestive) heart failure, chronic obstructive pulmonary disease, unspecified, Ischemic cardiomyopathy, schizoaffective disorder, bipolar type, hypothyroidism, unspecified, hyperlipidemia, unspecified, mild neurocognitive disorder due to known physiological condition without behavioral disturbance, peripheral vascular disease, unspecified. Review of R50's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 07/30/23 revealed she was edentulous. Review of the Brief Interview Mental Status (BIMS) score revealed R50 scored 12 out of 15 which indicated R50 had moderately impaired cognition. During an interview on 09/19/23 at 12:21 PM, R50 stated that she needed a dental appointment as she did not have teeth and would like dentures. Review of a resident appointment list provided on paper on 09/20/21 revealed that R50 did not qualify for the facility dental plan because she received Social Security Income (SSI). During an interview on 09/21/23 at 1:03 PM the Social Services Director (SSD) stated she consulted with the social work consultant to identify other payor sources and resources to assist residents with dental needs when the resident did not qualify for the facility dental plan. The SSD stated R50 was a previous resident at the facility and the family had previously informed her that they would take care of the dental needs and so the facility did not initiate services. The SSD stated she did not document the previous conversation with the family and there was no additional documentation regarding facility actions to assist the R50 for dental needs. 2. Review of R112's Face Sheet tab located on the home page in the EMR revealed the following diagnoses: chronic kidney disease, unspecified, Type 2 diabetes mellitus without complications, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic systolic (congestive) heart failure, essential (primary) hypertension, anemia, unspecified, hyperlipidemia, unspecified, major depressive disorder, single episode, unspecified, other abnormalities of gait and mobility and muscle weakness (generalized). Review of R112's admission MDS with an ARD of 09/03/23 revealed she had obvious or likely cavity or broken natural teeth. The Care Area Assessment section revealed a dental problem was triggered for care planning and documented, Resident has broken teeth which she states happened last year-resident denies pain/discomfort. Resident saw dentist prior to admission to facility and will see resident while in facility. Resident does have Diabetes Mellitus (DM) and takes medication which may impact oral health. During an interview on 09/19/23 at 11:28 AM, R112 stated her dental bridge broke during a fall prior to admission and she could feel the screws remaining from bridge in her mouth, which were painful and bothersome. Review of R112's Comprehensive Nursing Assessment located in the Data Collection tab of the EMR and dated 08/28/23, reflected: Mouth inspection: No visible problems to the mouth (i.e., lips moist and oral mucosa pink/moist). Review of R112's Nurses Notes tab in EMR on 09/20/23 revealed, Before she went to dialysis resident was complaining of the screws on the bridges in her mouth hurting her mouth. Will inform oncoming nurse and put on clinical dashboard that resident needs to see a dentist asap [as soon as possible]. During an interview on 09/21/23 01:03 PM, the SSD stated that an appointment had been made for R112 and provided a list which revealed her appointment as 10/05/23.

Based on record review, interview, and a review of the facility policy titled, Medication Orders, the facility failed to ensure accurate documentation of medical conditions for three (Resident (R) 27, R112, and R31) of 20 sample residents. These failures had the potential to contribute to inappropriate care or unnecessary medication use. Findings include: Review of the facility's policy titled Medication Orders, dated 2019 and provided on paper, revealed, Medication orders specify the following: -Full patient name -Name of medication -Strength of medication, where indicated -Dosage-Route of administration -Time or frequency of administration -Quantity or duration (length) of therapy . -Diagnosis or indication for use -Date and time of order Any dose or order that appears inappropriate considering the patient's age, condition, or diagnosis is verified with the prescriber. 1. Review of R27's Face Sheet of the electronic medical record (EMR) under the Resident tab revealed a diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke), aphasia (problems speaking), seizures, anemia, hypertension, urine retention, and neurogenic bladder. Review of R27's Orders tab of the EMR revealed the following active orders with inappropriate diagnoses: -Tamsulosin (used to treat symptoms of an enlarged prostate gland), 0.4 milligrams (mg) one time per day for a diagnosis of constipation. -Folic acid (a vitamin B-9 supplement used to treat anemia), 1 mg daily for a diagnosis of depression. -Levothyroxine (a medicine used to treat an underactive thyroid gland), 50 micrograms (mcg) daily for a diagnosis of seizure disorder. -Rosuvastatin (a medication that reduces the amount of cholesterol in the blood) 5 mg daily for a diagnosis of supplement. 2. Review of R112's Face Sheet, of the EMR under the Resident tab revealed a diagnoses including stroke, coronary artery disease, diabetes, hypertension, chronic kidney disease, anemia, hyperlipidemia, and congestive heart failure. Review of R112's Orders tab of the EMR revealed the following orders with inappropriate diagnoses: -Pregabalin (a medication that treats nerve and muscle pain), 50 mg once daily on Tuesday, Thursday, Saturday, and Sunday and twice daily on Monday, Wednesday, and Friday for a diagnosis of type 2 diabetes mellitus. -Rosuvastatin, 10 mg daily for a diagnosis of Major depressive disorder. -Senna (a laxative), 8.6 mg daily for a diagnosis of hypertension. -Tamsulosin, 0.4 mg daily for a diagnosis of hypertension. -Tramadol (a pain medication), 50 mg every 8 hours as needed for a diagnosis of hypertension. -Plavix (an antiplatelet drug to prevent blood clots), 75 mg every Tuesday, Thursday, Saturday and Sunday for a diagnosis of Major depressive disorder. 3. Review of R31's Face Sheet, of the EMR under the Resident tab revealed a diagnoses including: hypertension, heart failure, kidney failure, hypokalemia, thyroid disorder, Alzheimer's disease, and asthma. Review of R31's Orders tab of the EMR revealed the following orders with inappropriate diagnoses: -Bactrim (sulfamethoxazole/trimethoprim antibiotic medication), 800 mg/160 mg twice daily for a diagnosis of Alzheimer's disease. During an interview on 09/21/23 at 4:50 PM, the Director of Nursing (DON) stated on 08/01/23, the facility transitioned to a new EMR system, and the staff who entered physician orders were no longer able to input diagnoses into the system. She stated diagnoses were populated from the Minimum Data Set (MDS) assessment and the nursing staff who input orders could only select from a drop-down list of medications. The DON had not implemented any corrective measures to ensure diagnoses were input accurately with medication orders.

Based on interview, record review, and a review of the facility policy titled, Antibiotic Stewardship, the facility failed to identify trends in antibiotic use, maintain documentation for clinical indication of use for antibiotics, implement systematic protocols to monitor, decrease use and measure effectiveness of antibiotics and create an action plan to lower the use of antibiotics that did not meet criteria with the potential to effect 61 census residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship with a review date of 12/30/22 revealed that the team members included the Quality Assessment Performance Improvement (QAPI) committee members and other members were brought in on an as needed basis. The policy revealed that the facility's antimicrobial stewardship program included but not limited to formulary restriction, prospective audit and feedback by contracted pharmacy and feedback to physicians, staff, and physician education, parenteral to oral conversion protocol, dose optimization/automatic dose adjustment, streamlining/de-escalation of therapy, indication clarification required in patient record and ID consult when necessary. The policy revealed the DON/designee in collaboration with the QAPI team worked to educate departments of the facility whether they were involved directly or indirectly with patient care about stewardship. Review of the HAI [Healthcare Acquired Infections] Summary report, dated 07/23, revealed there were 11 infections in the month, 11 antibiotic starts in the facility, and three did not meet criteria. Six infections were recorded on B-hall and one on C-hall for fungal, oral, or perioral and skin infections. There were three additional infections identified as other. There was an error discrepancy for the number of total infections by unit, which totaled 11, but should have been 10. Record review of HAI Summary report, dated 08/23, revealed there was one infection of cellulitis, and 12 antibiotic starts. Eight did not meet criteria and were not indicated by unit. There was no specific information documented related to the type of antibiotic, reason for use, or prescriber to identify potential trends for antibiotic stewardship for 11 residents who received antibiotics that month, without the presence of infection. There was no additional documentation provided to address the discrepancies, rationale for antibiotic starts, and rationale for infections that did not meet criteria. During an interview on 09/21/23 5:52 PM the Division Regional Nurse (DRN) stated the report included the facility acquired, community acquired, and the not met antibiotic starts for each month. The DRN stated the wound nurse may not have had enough documentation at the time of the order and that would be why that antibiotic start did not meet criteria. The DRN and the Director of Nursing (DON) did not state a rationale for the evaluation of six residents on B-Hall with fungal type infections, for root cause, and transmission between residents or prevention. The DRN stated there needed to be more education on signs and symptoms, clinical indication for use, documentation for routine orders when a medication was refilled, and how to track it. The DRN and the DON could not explain why so many infections did not meet criteria or what actions the facility took in response.

Based on record review and interview, the facility failed to implement and maintain a training program for dementia training for one of two Certified Nurse Aides (CNA1) and emergency evacuation of bariatric residents for all staff. This failure had the potential to affect the care and services provided to 27 of the 61 residents with dementia and two bariatric residents reviewed in the survey sample of 20 in the facility. Findings include: 1. Review of two CNA educational documentation, chosen for a hire date greater than twelve months prior to the review, showed: CNA 1: Date of Hire 06/17/21 did not have documented dementia care training. 2. During the course of the investigation into two Resident's (R)1 and R43 interviewed that did not have wheelchairs that fit through their room doorways, a concern regarding emergency evacuation was raised and, on 09/21/23 at 1:03 PM the Administrator stated no training regarding emergency evacuation of bariatric patients had been done as part of the facility Emergency Preparedness Program (EPP). During an interview on 09/21/23 at 1:10 PM Licensed Practical Nurse LPN3 stated, During an emergency we would take out the residents that can walk, then those in wheelchairs and then those in their bed. The bariatric beds can be collapsed, and the assist bars removed to get the bed through the door. I have not received any training about the bariatric beds at this facility, I received training at a previous facility that I worked at. During an interview on 09/21/23 at 6:00 PM regarding training for bariatric resident evacuation, the Administrator stated No training prior to today, but it's being done now. There is no policy and the EPP only has general evacuation policies. After today, there will be a policy and training. When asked his expectation regarding dementia training for direct care staff, the Administrator stated, Expectation is that staff will receive training prior to working with residents and annually. In a follow-up interview on 09/21/23 at 6:17 PM, the Division Regional Nurse stated there was no policy regarding staff training.

Based on record review and interview, the facility failed to implement and maintain a training program regarding the prevention of abuse and neglect for one of two Certified Nurse Aides (CNA) 1 reviewed and one of two Licensed Practical Nurses (LPN) 1 reviewed for training. This failure had the potential to affect the safety, care, and services provided to the 61 residents in the facility. Findings include: Review of two CNA training transcripts, chosen for a hire date greater than twelve months prior to the review, showed: CNA1: Date of Hire 06/17/21 did not have documented abuse/neglect prevention training. Review of two LPN training transcripts, randomly chosen from the State Agency Personnel review form showed: LPN1: Date of Hire 12/10/21 had no documented abuse/neglect prevention training. During an interview on 09/21/23 at 6:00 PM, the Administrator stated it was an expectation that staff would receive training prior to working with residents and annually. During an interview on 09/21/23 at 3:23 PM the Division Regional Nurse (DRN) confirmed the training was not on the list but knew it was in a (facility computerized training program). The DRN stated she was going to check with the corporate office. No further documentation was provided. In a follow-up interview on 09/21/23 at 6:17 PM, the DRN stated there was no policy regarding staff training.

Based on record review and staff interviews, the facility failed to ensure two of two Certified Nurse Aides (CNA) 1 and CNA 4 and two of two Licensed Practical Nurses (LPN) 1 and LPN 2, reviewed had received behavioral health training to care for residents diagnosed with mental health illnesses indicated as admittable in the facility assessment. This failure had the potential for direct care staff to lack current knowledge to work with the unique challenges mental health illnesses present. Findings include: Review of the Facility Assessment, dated as reviewed on 09/18/23, showed: Diseases/conditions, physical and cognitive disabilities 13. List common diagnoses or conditions associated with the category in the space provided below. Category Psychiatric / Mood Disorders Diagnosis. Psychosis (Hallucinations, Delusions, etc) Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Anxiety Disorder, Unspecified Schizophrenia, Schizoaffective, Post Traumatic Stress Disorder, Behaviors not listed elsewhere, Pasarr level II. Review of two CNA training transcripts, chosen for a hire date greater than twelve months prior to the review, showed: CNA 1: Date of Hire 06/17/2021 did not have documented behavioral health training. CNA 4: Date of Hire 10/06/2021 did not have documented behavioral health training. Review of two LPN training transcripts, randomly chosen from the State Agency Personnel review form showed: LPN 1: Date of Hire 12/10/2021 had no documented behavioral health training. LPN 2: Date of Hire 08/16/2023 had no documented behavioral health training. Interview on 09/21/2023 at 6:00 pm, the Administrator stated an expectation that staff would receive training prior to working with residents and annually. Interview on 09/21/2023 at 3:23 pm the Division Regional Nurse (DRN) confirmed the training was not on the list but knew it was in a (facility computerized training program). The DRN stated she was going to check with the corporate office. No further documentation was provided. In a follow-up interview on 09/21/2023 at 6:17 pm, the DRN stated there was no policy regarding staff training.

Based on observation, interview, and record review the facility failed to ensure that six of six residents (Resident (R) 21, R29, R43, R44, R57, and R50) reviewed for bed rail use of 20 sample residents had documented safety assessment for the use of bed rails and the Resident or Resident Representative (RR) were advised of the risks and/or benefits of rail use. This failure had the potential for residents with bed rails to be uninformed of the risk of severe injury and/or death associated with bed rail use. Findings include: A request for a bed rail policy, on 09/20/23 at 5:35 PM the Division Regional Nurse (DRN) stated, We don't have a rail policy, it's just part of the admission assessment. I even called in compliance and there isn't one. 1. Review of R21's Face Sheet from the electronic medical record (EMR) Resident tab showed a medical diagnoses that included hemiplegia and hemiparesis following cerebral infarct, congestive heart failure, osteoarthritis, anxiety disorder, and hypertension. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/07/23 showed R21 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicative of being cognitively intact. During an observation and interview on 09/18/23 at 11:56 AM, R21 was observed to have bilateral assist bars attached to his bed. When asked if he had been advised of the benefits and risks of assist bars R21 stated, No, I didn't get talked to about that. Review of the R21's EMR Resident Summary tab, the Bed Rail/Assist Bar Assessment completed 11/16/22 showed: Current Status. Does the patient need assistance to get out of bed? [radio button for] Yes. Is there any equipment currently attached to the bed? No and initiation or change is not being considered. During an interview on 09/20/23 at 10:55 AM, the Division DRN stated there were no further assessments Review of R21's Care Plan from the EMR Care Plan tab showed on 09/14/23 a self-care deficit care plan that noted the use of assist bars for R21 to turn and position himself in bed. 2. Review of R29's Face Sheet from the EMR Resident tab showed a medical diagnoses that included femur fracture, seizures, hypertension, heart disease, schizophrenia, early onset Alzheimer's, gout, and polyneuropathy. Review of a quarterly MDS with an ARD of 08/17/23 showed a BIMS score of 4 out of 15, or indicative of severe cognitive impairment. During an observation and interview on 09/18/23 at 3:44 PM, it was observed that R29 had bilateral assist bars attached to the bed. When asked if he had been advised of the benefits and risks, he thought perhaps his sister had been advised. Review of the R21's EMR Resident Summary tab, the Bed Rail/Assist Bar Assessment completed 06/12/23 showed: Current Status. Does the patient need assistance to get out of bed? [radio button for] Yes. Is there any equipment currently attached to the bed? No and initiation or change is not being considered. During an interview on 09/20/23 at 10:55 AM. the DRN stated there were no further assessments. Review of R29's Care Plan, from the EMR Care Plan tab, showed a focus of a self-care deficit with a goal that the Resident will be able to assist with turning and positioning self in bed and an intervention of the assist bars to the bed. 3. Review of R43's Face Sheet from the EMR Resident tab showed a facility admission date of 04/24/23 with medical diagnoses that included hemiplegia and hemiparesis following a cerebral infarct, paroxysmal atrial fibrillation, convulsions, major depressive disorder, and dysphagia. Review of a quarterly MDS with an ARD of 08/22/23 showed R43 had a BIMS score of 15 out of a possible 15, indicative of being cognitively intact. During an observation and interview on 09/18/23 at 2:17 PM it was observed that R43 had bilateral assist bars attached to her bed. When asked if anyone had discussed the benefits and risks of the assist bars, R43 stated no. Review of the R43's EMR Resident Summary tab, the Bed Rail/Assist Bar Assessment completed 04/24/23 showed: Current Status. Does the patient need assistance to get out of bed? [radio button for] Yes. Is there any equipment currently attached to the bed? No and initiation or change is not being considered. During an interview on 09/20/23 at 10:55 AM. the DRN stated there were no further assessments R43's Care Plan from the EMR Care Plan tab showed she required assistance from sitting to lying in the bed, lying to sitting in the bed, and extensive assistance with bed mobility but did not note the use of assist bars. 4. Review of R44's Face Sheet from the EMR Resident tab showed a facility admission date of 02/07/23 with medical diagnoses that included type II diabetes, quadriplegia, anxiety disorder, hypertension, anemia, and major depressive disorder. Review of a quarterly MDS with an ARD of 08/08/23 showed R44 had a BIMS score of 11 out of 15, indicative of moderate cognitive impairment. During an observation and interview on 09/19/23 at 10:19 AM R44 was observed to have bilateral assist bars attached to the bed. R44 stated she did not use them, and nobody had discussed the benefits and risks of the bars. Review of the R44's EMR Resident Summary tab, the Bed Rail/Assist Bar Assessment completed 05/09/23 showed: Current Status. Does the patient need assistance to get out of bed? [radio button for] Yes. Is there any equipment currently attached to the bed? No and initiation or change is not being considered. During an interview on 09/20/23 at 10:55 AM. the DRN stated there were no further assessments. Review of R44's Care Plan from the EMR Care Plan tab showed she required assistance from sitting to lying in the bed, lying to sitting in the bed, and extensive assistance with bed mobility but did not note the use of assist bars. 5. Review of R57's Face Sheet from the EMR Resident tab showed a medical diagnoses that included disorganized schizophrenia, gout, hypertension, skull fracture, muscle weakness, need for assistance with personal care, traumatic subarachnoid hemorrhage, and dementia. Review of a quarterly MDS with an ARD of 07/26/23 showed R57 had a BIMS score of 12 out of 15, indicative of moderate cognitive impairment. During an observation and interview on 09/18/23 at 11:47 AM, it was observed that R57 had bilateral assist bars attached to the bed. When asked if he had been advised of the benefits and risks and consented, R57 stated he didn't remember benefits and risks or signing anything, but that he used the bars. Review of the R57's EMR Resident Summary tab, the Bed Rail/Assist Bar Assessment completed 03/11/23 showed: Current Status. Does the patient need assistance to get out of bed? [radio button for] Yes. Is there any equipment currently attached to the bed? No and initiation or change is not being considered. During an interview on 09/20/23 at 10:55 AM. the DRN stated there were no further assessments. Review of R57's Care Plan from the EMR Care Plan tab showed he had limited mobility and used assist bars to aid in bed mobility. During an interview on 09/21/23 at 6:00 PM, regarding bed rail use, the Administrator stated an expectation was that the assessment, risk/benefit advisement, and consent would be completed upon admission. 6. Review of R50's Face Sheet from the EMR Resident tab revealed diagnoses which included cerebral infarction, type 2 diabetes mellitus with diabetic nephropathy, congestive heart failure, chronic obstructive pulmonary disease, cardiomyopathy, schizoaffective disorder - bipolar type, hypothyroidism, hyperlipidemia, and dementia. Review of R50's admission MDS in the MDS tab of the EMR with an ARD of 07/30/23 revealed she required supervision with bed mobility and transfers. During an observation on 09/19/23 at 12:21 PM in R50's room, 1/4-length rails were on both sides of R50's bed at the head of the bed. During an interview, R50 stated she was unable to use the rails. R50 stated that she was able to move in bed without use of the rails and transfer independently to the wheelchair. Review of R50's EMR under the Data Collection tab revealed there was no assessment of her need for and use of the bed rails. During an interview on 09/21/23 at 10:28 AM the Director of Nursing, (DON) stated a bed rail assessment should have been completed for R50.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review, the facility failed to identify and provide dental services for one resident (R) (#1) related to an ongoing dental issue. The facility sample was 32 residents. Findings include: Review of the undated facility policy titled Skilled Inpatient Services: Dental Services/Oral Assessments revealed: 1. Intent: .to provide or obtain oral health care and dental services to meet the needs of each patient to the extent covered under State Law. 2. Guideline: Dental Services: if necessary or if requested by the patient, the center will assist the patient in making appointments and arranging transportation. Oral Assessments: should be completed on admission, annually, and as needed. R#1 was a [AGE] year old male admitted to the facility on [DATE] with diagnoses to include dementia without behaviors and right-eye blindness. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] documented under Section L/Dental, R#1 had obvious or likely cavity or broken natural teeth. Review of the Care Plan related to Dental, dated 6/15/2021 and updated 12/7/2021 revealed Obvious Cavity with interventions to include dental referral as needed, observe for pain, and provide assistance with oral care. Review of the Physician Orders dated 6/2/2021 revealed a diet order for mechanical soft [texture] with ground meats. During observation of R#1 in his room on 3/15/22 at 12:45 p.m., Licensed Practical Nurse (LPN) BB was feeding R#1 his lunch. During an observation/interview with R#1 on 3/15/22 at 1:22 p.m., when asked if he enjoyed his lunch, he stated he didn't eat much because it hurt to chew. He was observed with a loose bottom tooth which moved back and forth during conversation. He stated he hadn't seen the dentist in about a year. During an interview with LPN BB on 3/15/22 at 1:35 p.m., she stated R#1 ate 100% of his lunch and did not complain of pain when she fed him, and she did not note a loose bottom tooth. During an interview with the Director of Nursing (DON) on 3/16/22 at 3:01 p.m., she stated she was not aware R#1 had difficulty chewing. She stated R#1 had known dental problems but she was not aware he had any pain associated with it. She stated the contracted dentist visits quarterly, but she would have sent R#1 to an outside dentist to treat him if she had known. She stated she would request the Speech Therapist (SLP) evaluate R#1 to determine appropriate food texture and would review the dentist's last facility visit to see if R#1 was on the list. Review of the Dental Enrollment Detail Report dated 2/10/22 revealed R#1 was not scheduled to see the dentist during the facility visit. During a telephone interview with CNA FF on 3/17/22 at 11:00 a.m., she stated she had noted R#1's loose tooth and would normally report any new issue to the nurse related to pain, skin condition, or any other concerns. She stated she believed she reported R#1's mouth pain to the nurse within the last month but could not recall which nurse or exactly when. During an interview with LPN EE on 3/17/22 at 1:47 p.m., she stated no CNA had informed her of R#1's complaint or mouth pain which they are supposed to do for any identified issue or concern for their residents. During a joint interview with R#1 and his daughter during her visit on 3/17/22 at 1:55 p.m., she stated her dad has had dental problems for some time and had previously removed a loose tooth on his own. She asked R#1 if any other teeth were bothering him in addition to the loose tooth and he said, no. R#1 stated he would allow the dentist to remove the loose tooth.