**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure communication devices were utilized for 2 out of 3 residents reviewed (Resident #1 and Resident #2). Resident #1 had a communication device that used a button he controlled with his head to select words and phrases on a computer. The communication device could be used when it was not on his wheelchair(w/c). The nursing staff were not educated on how to use the communication device nor did they know they could use the communication device, therefore Resident #1 was communicating with the staff by answering yes or no questions only, limiting his ability to communicate his wants and needs to his full potential. Resident #2 had a picture board with pictures of items that she would/could frequently request. Staff interviewed did not know about a picture board for Resident #2 and stated they had not used the picture board with Resident #2. The picture board could not be found in this resident's room. The facility reported a census of 40 residents. Findings include: 1. Minimum Data Set/s (MDS/s) for Resident #1 dated 9/5/22, 12/1/22, 3/2/23, and 6/1/23 all had a Brief Interview of Mental Status score of 15 out of 15, which indicated intact cognition. The MDS dated [DATE], had a BIMS score of 0 out of 15, which indicated severe cognitive impairment. It documented that this resident was able to complete the BIMS. The Census sheet for Resident #1 documented that this resident admitted to the facility on [DATE]. It documented that the facility stopped billing on 12/28/23. The Medical Diagnoses Page for this resident showed his diagnoses included spastic quadriplegic cerebral palsy dated 8/29/22, epilepsy dated 8/29/22, and major depressive disorder, recurrent severe without psychotic features dated 3/30/23. A Care Plan directed that Resident #1 had been admitted to skilled level of care and that Speech Therapy would be working with Resident #1 with personalizing and making adjustments to his communication device. It was canceled on 9/20/22 but had a target date of 12/26/23. This Care Plan directed that the PASRR (Pre-admission Screening and Resident Review) had identified that Resident #1 could benefit from rehabilitative services with a target date of 12/26/23 and a cancel date of 12/28/23. It directed that assistance with assistive technology be overseen by the facility Social Worker. This intervention had a start date of 8/29/22 and was resolved on 12/11/23. On 1/23/24 at 10:45 a.m., Staff A, Speech Therapist (ST), stated they have two companies that provide communication devices and services for the device, repairs, tech support, and that kind of thing. This ST stated they had three residents with communication devices and now the facility had two residents that had communication devices. Staff A stated that 1 resident, Resident #1, discharged closer to his family. She stated that the facility did have some technical issues with the switch Resident #1 used. Staff A stated Resident #1 used a head switch in his head support on his w/c. She stated Resident #1's communication device would show him phrases or words and he would make selection with the head switch. Staff A stated Resident #1 was able to use the communication device when he was in bed too. She stated that staff knew how to help him with that. Staff A stated she did not know of any concerns from him that he was unable to use the device. Staff A stated it worked via blue tooth. She stated that occasionally they would have to reboot the device so it would pair with the blue tooth. She stated Resident #1 used the device often. He could answer yes/no questions-by nodding or shaking his head. She stated that she often would see Resident #1 using the device in bed as well as in his w/c. On 1/23/24 at 12:24 p.m., Staff B, Certified Nurse Aide (CNA), stated that Resident #1 used his communication device when he first got to the facility before his chair broke. Staff B stated they could meet his needs as Resident #1 would tell them yes or no. Staff B stated that this resident preferred to stay in bed. Staff B stated she did not see him use his communication device in bed. She stated he always communicated with them by head gestures yes or no. On 1/23/24 at 12:30 p.m., Staff A, ST stated that Resident #1 was proficient with his communication device so she did not have him on their caseload. On 1/23/24 at 12:35 p.m., Staff C, CNA, stated that Resident #1 only used his communication device for the first year that he came but then after that she didn't see it. She stated the reason he wasn't using it had something to do with the chair. She said the communication device was impossible to use in bed. He had to be in the chair to use it. She stated he would communicate with staff by answering yes/no questions. Staff C stated that when his chair was working he used the communication device all of the time. Staff C added that Resident #1 really liked to use it. Staff C stated she would say that Resident #1 was upset that he couldn't use the communication device anymore but he never told Staff C that but he really only could answer yes or no questions. After his chair broke, they did fix it but he needed a piece for the communication device. He never did get the part on the w/c and discharged without being able to use his communication device again. Staff C said that it was a good year that he went without the communication device. On 1/23/24 at 12: 45 p.m., Staff D, CNA stated that she had only worked at the facility for a month. She stated that she noticed Resident #1 moved out of the facility. She stated that Resident #1 did not use a communication device. On 1/23/24 at 12:50 p.m., Staff A stated that she definitely had seen Resident #1 using his communication device in bed. She said there should be documentation regarding Resident #1 using the communication device in bed. She stated that Resident #1 had a stand as well that they could put the computer on. Staff A stated that it was used mostly with his family when they visited. On 1/23/24 at 1:00 p.m., Staff A stated that Staff E, Speech Restorative Aide was the one who would use the communication device to meet with Resident #1. Staff E no longer worked at this facility. On 1/23/24 at 1:45 p.m., Staff F, CNA stated that Resident #1 used the communication device until his w/c broke. He was not able to use it in bed or in a geri chair (a padded reclining chair on wheels). She stated he communicated with yes or no answers. On 1/23/24 at 2:40 p.m., the Director of Nursing (DON), the Licensed Nursing Home Administrator (LNHA), Staff G, Social Worker (SW), Staff H, Nurse Manager, and Staff I Nurse Manager/MDS Coordinator came in to talk about Resident #1's communication device. Staff G stated Resident #1 was unable to answer the MDS questions without the device, so that is why she was unable to have him answer the BIMS questions on the most recent MDS's. The group stated that he was able to use the device in a geri-chair but it took at least 2 staff to help hold him up right as he was so spastic. They had to replace many buttons (used to choose words or phrases that he could see on his computer). The w/c he came with had zip ties, shoe strings, and duct tape all over it. They finally were able to replace his w/c but did not get the right parts to hook the communication device back on to it. Staff H stated that he opted not to get up in the geri chair very often because he hurt when he sat in it. He would get up for meetings and it would take several of them to assist him with working the communication device. She stated he couldn't use it in bed because of the spasms. Staff H stated that Resident #1 took bed baths because he refused the shower chair. He couldn't activate his call light because of his spasms. The SW and DON pointed out that they still gave him the call light and would always answer it if it did go off. They stated he would yell out if he needed something. He was very verbal. It sounded somewhat like a loud guttural sound and he would sometimes do this when he saw staff walking by. When asked about the speech restorative person using the device in bed or on the stand-almost daily they stated they didn't know anything about that. They would have to verify that with her. Stated they had replaced many buttons for him and many wires as he would have a spasm and knock the wire out that connected the communication device to his computer. They at one point switched it to Blue Tooth but then there were issues with the 2 devices syncing. A timeline was requested of chair breaking down and communication device issues. On 1/23/24 3:20 p.m., the LNHA stated for a timeline on the communication device, it's difficult because it was always hit or miss. Something would go wrong and they would try to fix it. She stated her IT (Information Technology) guy had worked on it a few times as well. The communication device was made for the wheelchair and was old. The IT staff tried to adapt the communication device to be used off of the w/c and it was difficult to do. When asked about wasn't there another way to administer the MDS when a resident has communication difficulties, the Administrator stated that the SW had checked with corporate office to see how she was to code his MDS. The administrator said that the IT person would not have made notes on what he tried to help with. The manufacturer would have made the repairs needed. The IT staff would have just tried to make things work in the meantime. She will look for any documentation from the company that serviced the communication device. On 1/23/24 at 3:35, the LNHA brought in SW notes stating the notes show somewhat of a timeline for repairs with his communication device and wheelchair. She stated she understands the concerns and is trying to figure out the best way to get the information. On 1/23/24 4:05 p.m., Resident #1's Current Caregiver stated that Resident #1 had an attorney and that was how he was able to get a new w/c and how he was able to go to a different care providing service. She stated that Resident #1 had been failing for about 9 months. She stated he now has a new wheelchair and his doctor had put in an order for his headrest to be revamped so the communication device would work. On 1/23/24 at 4:08 p.m., a Facetime call was placed to Resident #1 with his current caregiver holding the phone. Resident #1 did not have a communication device and they are in the process of getting one. He can answer yes or no questions. Resident #1: nodded emphatically yes to feeling emotionally distraught related to not being able to use his communication device to communicate with the staff while at the facility He nodded yes to the staff not using the communication device to talk with him while in bed. He nodded yes to using the communication device while in a geri chair and nodded yes to it taking more than one staff to assist with this at times. He nodded yes to the facility assisting with this for meetings with his case worker. He nodded yes emphatically to feeling depressed regarding not using his communication device. He nodded yes to not wanting to get up for showers. This resident shook his head no when asked if he didn't want to get up out of bed and into a geri chair. He nodded yes when asked if he refused to get up sometimes but that didn't mean he didn't want to get up all the time. He nodded yes to the speech restorative aide/Staff E using the communication device with him while he was in bed. He nodded yes to enjoying those moments when he could use his device to communicate He nodded yes to having a stand that the communication device could be placed. He nodded yes to his family using this device when they would visit him at the facility. On 1/23/24 at 5:15 p.m., Staff E, stated Resident #1 used his communication device pretty much all of his life, or at least some kind of communication device. She stated he could answer yes or no questions without the device. She thought she talked with Resident #1 at least twice a week. When asked how long she had been meeting with him, she stated pretty much two times a week for the whole time he had been at the facility. She never saw any of the CNAs using the communication device to talk with him. She said Resident #1 would have preferred using his device instead of answering yes or no questions with staff. She stated that Resident #1 was really proficient at using the device and again stated he had been using a device for pretty much all of his life. She stated she did not take notes on their visits as he was not on a speech program. She stated that she stopped in twice a week just to check in on him. On 1/24/24 at 11:30 a.m., the DON and LNHA asked what was needed. Shared that the concern is that the ability was there to use the communication device and it wasn't being used. Staff E used it twice a week pretty much since he arrived at the facility to communicate with this resident. When asked about the family using the device when they came, the DON stated that yes the family did use the communication device. The DON stated the facility would set that up for the family. On 1/24/24 at 11:46 a.m., Staff J, Program Coordinator/CNA/CMA(Certified Medication Aide), stated that Resident #1 could say yes or no. She stated he could say other words too. Once you get to know him you can understand him if you ask him things. Staff J then said she guessed you would have to ask yes or no questions. She stated that she had never saw him use his communication device in bed. She stated the facility got the tri pod and she had tried to set it up. She stated that she thought Staff E worked with him using the tri pod. Staff J stated that when he was in the chair the communication device worked really well. Staff J did not know how he would use the communication device while lying in bed anyway. She said she didn't know how it would work out. She stated the CNAs would basically go in and ask Resident #1 if he wanted the TV or something on and he would answer yes or no. Staff J stated that if Resident #1 seemed upset, they could figure out what he needed. She said he would make noise if he needed something and they would assist him. She stated they would ask him a couple of questions and within those couple questions we could figure out what he needed. He would use the communication device all the time when the chair was working. He was very funny and very intelligent. Staff J stated that when they got him up he was uncomfortable with getting up in the geri chair (not his wheelchair) and would want to lay right back down. Staff J stated during Covid isolation it was really awful, residents were so lonely. Staff J stated she didn't know if he felt that way. She stated understanding that he wasn't using a communication device with the staff and that took away the ability to tell them more. She stated he did use the device easily when it was on his w/c. Staff J stated she could see how that might have impacted him. Staff J stated that most of the time he had a smile on his face and when she left the room, he seemed content. Staff J stated she wouldn't be able to say if he was feeling otherwise. Staff J stated she could put herself in his shoes, and if it were her, she would want to be able to use the device so she could communicate her feelings. On 1/24/24 at 1:15 p.m., the SW was asked if she had done all MDS's prior to the one done in 8/2023 with Resident #1 using his communication device. She stated she only used the communication device on the admission/initial MDS and was not able to use it after that. She did not know how she did the MDS's without the device and could not find documentation on how she completed it. She would keep looking for documentation. She stated that Resident #1 was a very intelligent young man and that he had no signs of decline in his cognitive status. The SW was not aware that his communication device could have been used. She stated that she called the office regarding how to do his MDS in August of 2023 and they directed her to document the staff response questions for the MDS and not document as his answers. A SW progress note dated 9/6/22 at 1:16 p.m., documented that Resident #1's Disability Attorney called to check on Resident #1. She inquired about his transition to the facility and how he was doing. SW informed Attorney about a couple of Resident #1's statements; This is the best place for me medically but not mentally, and l am too smart for this place. Resident #1 has asked his Dad if he will be here forever. On 09/02/2022 Resident #1's Mom and Grandmother came to visit him and the SW informed the family of these same statements. Mom stated that it may be possible for him to take online classes but she would consult one of his sisters, who is a professor. The SW shared this information with the Attorney because she believed that his mental state of mind can play a factor in his health. Attorney stated that she will periodically call and check on Resident #1. A SW note dated 9/7/22 at 3:27 p.m., documented the Disability Attorney called the facility at 1 :37 PM for a Zoom Call that was supposed to happen at 1 :30 PM. This resident was in bed at the time. Case Manager joined the call about 15-20 minutes later. Once the resident was in his chair, the head rest was off centered so he was not able to use his communication device to speak with the Attorney. Multiple people were in and out of the room to try to adjust his headrest; Nurse Manager, a Med Aide, two CNAs, Environmental Supervisor, the Occupational Therapist (OT), and the SW. It was very noticeable today that the headrest was positioned different. Attorney expressed her concern about this resident not being able to communicate to staff but SW assured the Attorney that the resident had been able to communicate to staff, it seems the problem did not arise until today. The best conclusion was for the Case Manager to contact the individual who used to adjust this resident's chair for possible repairs. Staff will need to be educated on the functions of Resident #1's device, and other functions of his chair. Attorney stated that she will call the facility at another time to discuss the repairs of the headrest and also to reschedule the Zoom call that she initially called for. The Zoom call was supposed to be private (no staff assistance). A SW note dated 9/21/22 at 3:00 p.m., documented that a service man came to the facility to assess the Resident's chair. He stated that the headrest was very loose and needed tightening. It appeared that he tightened the headrest and exited the building in a quick manner. SW noticed the difference in the headrest but Resident was in bed in order to try out adjustments. OT was out on a home visit when he arrived to the facility. A SW Note dated 11/10/22 at 2:23 p.m., documented that this resident's uncle came to the facility today for a visit. SW introduced herself to the uncle and told him where he could find SW office if he needed anything. The uncle came to the SW office to ask if Resident #1 had his communication device at this facility. SW went to Resident #1's room and noticed that his Device was sitting on the sink countertop. SW found the wire to his device tucked under his wheelchair broken into two pieces ([NAME] wires). The uncle put the wires back together and put black tape on them. SW plugged in device as it was dead. Resident #1 was then able to communicate with his uncle. This resident also wanted his wheel chair adjusted but the wheelchair was dead. A CNA came to show SW and the uncle how to charge the chair and she also adjusted a brace on the chair. SW was very surprised that there was not a note about Resident #1's communication device being disabled. SW spoke with Resident #1 on Tuesday and the communication device was working properly. SW will talk with therapy to clarify if the facility would have to order a new wire or if IT can do it. SW will notify Nurse Manager of these issues and continue to follow progress. A SW note dated 11/25/22 at 4:10 p.m., documented the Nurse Manager, IT, and SW are aware of Resident #1's issues with his communication device. We are working hard to resolve this issue as soon as possible. Family and Administrator has been notified. SW will continue to follow. A SW note dated 12/1/22 at 10:32 a.m., documented Resident #1 was in his room in his chair when SW approached him to conduct the MDS assessment. Resident #1 had a BIMS score of 15 and a PHQ-9 score of 04. This resident indicates that he has little interest or pleasure doing things 7-14 days within the last two weeks. He also expressed feeling down or depressed around the same frequency. Recently, this resident has been having issues with his communication device, which could play a role with how he feels. After consulting with the device tech support, they are confident that he needs a new head switch to operate the device. A speech pathologist will be consulted to support the next steps with fixing this ongoing issue. SW will continue to follow until the device has been serviced and then this resident can be reevaluated to see if his mood has changed. A SW Note dated 6/12/23 at 10:59 a.m., documented that Resident #1 had a meeting today with his Disability Right's lawyer and Disability Rights Advocate. His lawyer came to the facility to obtain consents from Resident #1 to work on the case of his wheel chair being repaired. Resident #1 has been waiting for months to get parts for his chair and more recently, was denied to pay for parts because it is the facility's responsibility according to the Provider's Manual. His lawyer is trying to see how she can fight this situation . SW will continue to follow. A SW Note dated 08/31/23 at 9:51 a.m., documented that the SW conducted the Staff MDS assessment with CNA. Resident #1 is usually able to respond to interview questions himself, but he is not able to use his device due to ongoing wheel chair repairs. SW will re-conduct assessment after Resident #1 is able to use his device again. There are not any cognitive changes that staff are aware of at this time. Resident #1's attorney is working hard to hold insurance accountable for wheelchair repairs. The team is working hard as well to help find placement out in the community for this resident. SW will continue to follow progress. A SW Note dated 11/28/23 at 12:24 p.m., documented SW conducted the Staff MDS assessment with a CNA. Upon conclusion of the interview, Staff believes that this resident may have felt down two times within the last couple of weeks due to the holidays and wanting to be with the new host-home within the community. Staff also indicates that this resident's short and long term memory is ok. Staff believes that this resident is aware of the current season and is aware of staff names and faces. Overall, Resident #1 appears to be cognitive to time, place, and people around him. There were no changes to code status at this time and the goal for him to return to the community is currently active. A Nursing Note dated 5/5/23 at 10:19 p.m., documented that the nurse (Staff H) would like to have speech therapy do an evaluation with resident to take a look at his communication device to see if they can write up steps for staff on how to set it up properly for him to use. A Doctor's Order dated 5/9/23, directed a speech evaluation be done for communication device directions for staff. On 1/24/24 at 2:45 p.m., the DON and LNHA stated they were not aware of an order regarding Speech Therapy providing education to staff on how to use Resident #1's communication device. They acknowledged the concern regarding Resident #1's communication device was not being utilized by the staff for ease of communication. They acknowledged the concern that this could have impacted his mental health and his well-being. 2. A MDS dated [DATE], documented that diagnoses for Resident #2 included cerebral palsy and intellectual disabilities. The BIMS was answered by staff and indicated that this resident's cognition was severely impaired. A Care Plan directed staff that sometimes Resident #2 has problems communicating related to being non-verbal. Resident #2 would maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately, through the review date. The target date was 2/6/24. On 1/23/24 at 10:45 a.m., Staff A stated that Resident #2 had low tech picture pages that staff can use to communicate with her. There was a picture of suctioning on it for Resident #2 let staff know that she would like to be suctioned as Resident #2 requests this often. On 1/23/24 at 12:24 p.m., Staff B stated Resident #2 smiles when the answer is yes. Her aunt has told us she doesn't like to lie down. When we check and change her she makes a face like she is going to cry until she gets back up. Staff B stated they can tell what she wants/needs because of her smiling or a dissatisfied facial expression. She likes to be up out of her room and out here in the dining room. Following the above interview, the Licensed Nursing Home Administrator went into the resident room and was unable to locate the low tech picture pages. On 1/23/24 at 12:35 p.m., Staff C stated that Resident #2 communicates by moving her head yes or no. We know what she wants with cares as she can communicate that to us. Staff C stated she had not seen a picture board/pages that they were to use with her. On 1/23/24 at 12: 45 p.m., Staff D stated that Resident #2 sometimes would look down for yes or move head side to side for no. On 1/24/24 at 11:46 a.m., Staff J stated that she had never seen Resident #2 use a picture board/pages. On 1/24/24 at 1:30 p.m., Staff A stated the picture boards were kept on Resident #2's bedside table. Staff A stated she looked for them as she was just asked about them and could not find them. Staff A stated that Resident #2 was packed up as she was going to move out of state but now she was not going to move. When told that the staff were unaware that there was a communication board with pictures on it, she stated they should have known. This Speech Therapist stated the communication aides were left in sight so that staff could use them. She stated they were on the bed side table. On 1/24/24 at 2:45 p.m., the DON and LNHA acknowledged the concern that Resident #2 had a picture board to aide in communication. They acknowledged that staff reported not knowing about the picture board. The administrator stated they are unable to locate the picture board. An undated Enhancing and Maintaining Quality of Life policy, directed the following to staff: The facility will care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. The facility will provide reasonable accommodations of residents' individual needs and preferences related to their care and environment, directed toward assisting the resident to maintain and/or achieve their highest practicable level of functioning, promoting dignity and well-being, except when the health or safety of the individual or other residents would be endangered The facility will provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident.